Abstrakt Urologie Leden 2010

“Oncological Outcomes After Radical Cystectomy for Bladder Cancer: Open Versus Minimally Invasive Approaches.”

Chade, D. C., V. P. Laudone, et al. (2010).

J Urol.


PURPOSE: The number of centers performing robotic assisted radical cystectomy has recently increased, spurring greater concerns about oncological outcomes. In this review we summarize the most comprehensive articles published on the oncological outcomes of laparoscopic assisted, robotic assisted and open radical cystectomy. MATERIALS AND METHODS: A MEDLINE(R)/PubMed(R) literature search was conducted in March 2009 to review English language articles published from 1998 onward. Of 217 selected articles on the 3 techniques 19 studies were selected for this review. RESULTS: The laparoscopic series reported recurrence-free survival rates in the range of 83% to 85% at 1 to 2 years and 60% to 77% at 2 to 3 years, while the robotic assisted studies reported recurrence-free survival rates of 86% to 91% at 1 to 2 years. Large open surgery studies showed 62% to 68% recurrence-free survival at 5 years and 50% to 60% at 10 years, with overall survival of 59% to 66% at 5 years and 37% to 43% at 10 years. Overall survival in the laparoscopic cohorts was 90% to 100% at 1 to 2 years and 50% to 87% at 2 to 3 years. Publications reporting robotic cases demonstrated a 90% to 96% overall survival in 1 to 2 years of followup. CONCLUSIONS: Despite the surge of centers adopting minimally invasive approaches for radical cystectomy, the long-term effectiveness of these techniques has not yet been proven. This review of recent and landmark articles on open and minimally invasive procedures emphasizes the need for prospective controlled studies and long-term followup data to determine the proper use of laparoscopic and robotic assisted techniques in bladder cancer surgery.




“Robot-assisted laparoscopic removal of extraluminal leiomyoma confused with urachal cyst.”

Jeong, W., E. R. Sung, et al. (2009).

Journal of Robotic Surgery: 1-3.


Pedunculated extra-luminal leiomyoma is a rare solid tumor. We present a case of a 20-year-old Caucasian woman with a painful pedunculated extraluminal mass located on the bladder dome and associated with dysuria. She underwent robot-assisted laparoscopic resection, and the histological findings confirmed a leiomyoma. © 2009 Springer-Verlag London Ltd.




“Prospective Randomized Controlled Trial of Robotic versus Open Radical Cystectomy for Bladder Cancer: Perioperative and Pathologic Results.”

Nix, J., A. Smith, et al. (2010).

European Urology 57(2): 196-201.


Background: In recent years, surgeons have begun to report case series of minimally invasive approaches to radical cystectomy, including robotic-assisted techniques demonstrating the surgical feasibility of this procedure with the potential of lower blood loss and more rapid return of bowel function and hospital discharge. Despite these experiences and observations, at this point high levels of clinical evidence with regard to the benefits of robotic cystectomy are absent, and the current experiences represent case series with limited comparisons to historical controls at best. Objective: We report our results on a prospective randomized trial of open versus robotic-assisted laparoscopic radical cystectomy with regard to perioperative outcomes, complications, and short-term narcotic usage. Design, setting, and participants: A prospective randomized single-center noninferiority study comparing open versus robotic approaches to cystectomy in patients who are candidates for radical cystectomy for urothelial carcinoma of the bladder. Of the 41 patients who underwent surgery, 21 were randomized to the robotic approach and 20 to the open technique. Intervention: Radical cystectomy, bilateral pelvic lymphadenectomy, and urinary diversion by either an open approach or by a robotic-assisted laparoscopic technique. Measurements: The primary end point was lymph node (LN) yield with a noninferiority margin of four LNs. Secondary end points included demographic characteristics, perioperative outcomes, pathologic results, and short-term narcotic use. Results and limitations: On univariate analysis, no significant differences were found between the two groups with regard to age, sex, body mass index, American Society of Anesthesiologists classification, anticoagulation regimen of aspirin, clinical stage, or diversion type. Significant differences were noted in operating room time, estimated blood loss, time to flatus, time to bowel movement, and use of inpatient morphine sulfate equivalents. There was no significant difference in regard to overall complication rate or hospital stay. On surgical pathology, in the robotic group 14 patients had pT2 disease or higher; 3 patients had pT3/T4 disease; and 4 patients had node-positive disease. In the open group, eight patients had pT2 disease or higher; five patients had pT3/T4 disease; and seven patients had node-positive disease. The mean number of LNs removed was 19 in the robotic group versus18 in the open group. Potential study limitations include the limited clinical and oncologic follow-up and the relatively small and single-institution nature of the study. Conclusions: We present the results of a prospective randomized controlled noninferiority study with a primary end point of LN yield, demonstrating the robotic approach to be noninferior to the open approach. The robotic approach also compares favorably with the open approach in several perioperative parameters. © 2009 European Association of Urology.




“Robotic Radical Cystectomy for Bladder Cancer: Surgical and Pathological Outcomes in 100 Consecutive Cases.”

Pruthi, R. S., M. E. Nielsen, et al. (2010).

Journal of Urology 183(2): 510-515.


Purpose: Radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. Recently some surgeons have begun to describe outcomes associated with less invasive surgical approaches to this disease such as laparoscopic or robotic assisted techniques. We report our maturing experience with 100 consecutive cases of robotic assisted laparoscopic radical cystectomy with regard to perioperative results, pathological outcomes and surgical complications. Materials and Methods: A total of 100 consecutive patients (73 male and 27 female) underwent robotic radical cystectomy and urinary diversion at our institution from January 2006 to January 2009 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes and complication rate. Results: Mean age of this cohort was 65.5 years (range 33 to 86). Of the patients 61 underwent ileal conduit diversion, 38 received a neobladder and 1 had no urinary diversion (renal failure). Mean operating room time for all patients was 4.6 hours (median 4.3) and mean surgical blood loss was 271 ml (median 250). On surgical pathology 40% of the cases were pT1 or less disease, 27% were pT2, 13% were pT3/T4 disease and 20% were node positive. Mean number of lymph nodes removed was 19 (range 8 to 40). In no case was there a positive surgical margin. Mean days to flatus were 2.1, bowel movement 2.8 and discharge home 4.9. There were 41 postoperative complications in 36 patients with 8% having a major complication (Clavien grade 3 or higher) and 11% being readmitted within 30 days of surgery. At a mean followup of 21 months 15 patients had disease recurrence and 6 died of disease. Conclusions: We report a relatively large and maturing experience with robotic radical cystectomy for the treatment of bladder cancer providing acceptable surgical and pathological outcomes. These results support continued efforts to refine the surgical management of high risk bladder cancer. © 2010 American Urological Association.




“Robotic-Assisted Laparoscopic Intracorporeal Urinary Diversion.”

Pruthi, R. S., J. Nix, et al. (2010).

Eur Urol.


BACKGROUND: Recent small case series have now been reported for robotic-assisted laparoscopic radical cystectomy (RALRC). In most of these series, the urinary diversion has been performed in an extracorporeal fashion. There have been few case reports of an intracorporeal diversion and little description of the technique of such a procedure. OBJECTIVE: In this paper, we report our initial experience with robotic-assisted laparoscopic intracorporeal urinary diversion, describing stepwise the surgical procedure itself and evaluating perioperative and pathologic outcomes of this novel procedure. DESIGN, SETTING, AND PARTICIPANTS: We studied a single-institution case series of patients undergoing robotic-assisted cystectomy and intracorporeal urinary diversion for clinically localized urothelial carcinoma of the bladder (n=10) or for a noncompliant dysfunctional bladder refractory to more conservative management (n=2). Historical comparisons are also made to a consecutive case series of 20 patients undergoing robotic radical cystectomy and extracorporeal urinary diversion. SURGICAL PROCEDURE: RALRC and intracorporeal urinary diversion, including ileal conduit (n=9) and orthotopic ileal neobladder (n=3). MEASUREMENTS: The stepwise operative procedure is described in detail. Outcome measures evaluated in this series included operative variables, hospital recovery, and complication rate. Comparisons were made to a contemporaneous series of 20 patients who underwent a robotic cystectomy with extracorporeal diversion during this time period (from an experience of >100 robotic cystectomy patients since 2005). RESULTS AND LIMITATIONS: Twelve patients (mean age: 60.9 yr) underwent an intracorporeal diversion. Mean operating-room time of all patients was 5.3h, and mean surgical blood loss was 221ml. Mean time to flatus, bowel movement, and hospital discharge was 2.2 d, 3.2 d, and 4.5 d, respectively. Eleven of the 12 patients were discharged on or before postoperative day 5. There were six postoperative complications in five patients (42%), with one complication being Clavien grade 3 or higher. The major limitations of the study are the small sample size and the nonrandomized nature of the compared treatment groups (intracorporeal vs extracorporeal), which limits the ability to directly compare the techniques at a high level of scientific confidence. CONCLUSIONS: Our initial experience with robotic-assisted laparoscopic intracorporeal diversion appears to be favorable with acceptable operative and short-term clinical outcomes.




“Cost Analysis of Robotic Versus Open Radical Cystectomy for Bladder Cancer.”

Smith, A., R. Kurpad, et al. (2010).

Journal of Urology 183(2): 505-509.


Purpose: Recently robotic approaches to cystectomy have been reported, and while clinical and oncological efficacy continues to be evaluated, potential financial costs have not been clearly evaluated. In this study we present a financial analysis using current cost structures and clinical outcomes for robotic and open cystectomy for bladder cancer. Materials and Methods: The financial costs of robotic and open radical cystectomy were categorized into operating room and hospital components, and further divided into fixed and variable costs for each. Fixed operating room costs for open cases involved base cost as well as disposable equipment costs while robotic fixed costs included the amortized machine cost as well as equipment and maintenance. Variable operating room costs were directly related to length of surgery. Variable hospital costs were directly related to transfusion requirement and length of stay. The means of the prior 20 cases of robotic and open cystectomy were used to perform a comparative cost analysis. Results: Mean fixed operating room costs for robotic cases were $1,634 higher than for open cases. Operating room variable costs were also higher by a difference of $570, directly related to increased operating room time. Hospital costs were nearly identical for the fixed component while variable costs were $564 higher for the open approach secondary to higher transfusion costs and longer mean length of stay. Based on these findings robotic cystectomy is associated with an overall higher financial cost of $1,640 (robotic $16,248 vs open $14,608). Cost calculators were constructed based on these fixed and variable costs for each surgical approach to demonstrate the expected total costs based on varying operating room time and length of stay. Conclusions: Robotic assisted laparoscopic radical cystectomy is associated with a higher financial cost (+$1,640) than the open approach in the perioperative setting. However, this analysis is limited by its single institution design and a multicenter followup study is required to provide a more comprehensive analysis. © 2010 American Urological Association.




“Current status of robot-assisted radical cystectomy.”

Smith, A. B., M. E. Nielsen, et al. (2010).

Curr Opin Urol 20(1): 60-64.


PURPOSE OF REVIEW: To assess the current status of robot-assisted radical cystectomy with pelvic lymphadenectomy and urinary diversion for the treatment of bladder cancer. RECENT FINDINGS: Robot-assisted radical cystectomy is steadily growing with a feasible learning curve in those experienced in robotic prostatectomy. Pelvic lymphadenectomy appears to provide adequate nodal yield in several studies. Urinary diversions are most commonly performed extracorporeally, but several centers are attempting intracorporeal techniques. Short-term perioperative outcomes appear acceptable, but oncologic efficacy remains unknown. SUMMARY: Robot-assisted radical cystectomy with urinary diversion appears to be growing steadily in academic institutions. Long-term data regarding oncologic efficacy remain lacking but perioperative outcomes appear favorable.




“Robotic-assisted Laparoscopic Reconstruction of the Upper Urinary Tract: Tips and Tricks.”

Thiel, D. D., T. J. Leroy, et al. (2010).



Objectives: To examine whether simple tips and tricks provided in this manuscript and make robotic reconstruction of the urinary tract possible from the renal calyx to the bladder. The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) has been widely accepted by urologists for complex reconstructive maneuvers such as radical prostatectomy and pyeloplasty. Methods: The manuscript and accompanying outline tips and tricks for patient selection, patient evaluation, port placement, dissection techniques, robotic docking, ureteral repair, and stent management for complex urinary tract reconstruction of the upper urinary tract from the level of the renal calyx to the bladder. Results: Modifications such as port placement, robotic docking techniques, and ureter reconstruction have simplified the technique of complex robotic-assisted laparoscopic reconstruction of the urinary tract. Conclusions: Numerous scenarios can be encountered during robotic-assisted laparoscopic repair of the upper urinary tract. Simple tips and tricks provided in this manuscript and make robotic reconstruction of the urinary tract possible from the renal calyx to the bladder. © 2009 Elsevier Inc. All rights reserved.




“Robotic Cystectomy: Its Time Has Come.”

Vira, M. A. and L. Richstone (2010).

Journal of Urology 183(2): 421-422.




“Robot-assisted partial nephrectomy: evolution and recent advances.”

Benway, B. M. and S. B. Bhayani (2010).

Curr Opin Urol.


PURPOSE OF REVIEW: Robot-assisted partial nephrectomy (RAPN) is emerging as a viable complement to traditional laparoscopic and open partial nephrectomy. As a relatively new technique, the techniques and technologies employed during RAPN continue to evolve. In the present article, we provide an overview of the evolution of robot-assisted renal surgery, and highlight the recent advances that have helped to bring RAPN to the fore. RECENT FINDINGS: The learning curve for RAPN appears to be slight, and technical proficiency may be quickly achieved, even for those with limited laparoscopic experience. Recent advances include improvements in ergonomics of the robotic system itself, as well as the introduction of sliding-clip renorrhaphy, early unclamping techniques, and off-clamp techniques. Early-to-intermediate outcomes are very promising, demonstrating short warm ischemic times, and a low rate of complication and recurrence. Disadvantages to the approach include substantial cost, as well as increased reliance upon the assistant to perform critical maneuvers. SUMMARY: Robot-assisted partial nephrectomy appears to be a safe and efficacious technique for the surgical management of localized renal malignancy. Recent developments have focused upon reducing ischemic insult, as well as decreasing reliance upon the assistant.




“Live donor nephrectomy: A review of evidence for surgical techniques.”

Dols, L. F. C., N. F. M. Kok, et al. (2010).

Transplant International 23(2): 121-130.


Live kidney donation is an important alternative for patients with end-stage renal disease. To date, the health of live kidney donors at long-term follow-up is good, and the procedure is considered to be safe. Surgical practice has evolved from the open lumbotomy, through mini-incision muscle-splitting open donor nephrectomy, to minimally invasive laparoscopic techniques. There are different minimally invasive techniques, including standard laparoscopic, hand-assisted laparoscopic, hand-assisted retroperitoneoscopic, pure retroperitoneoscopic, and robotic-assisted live donor nephrectomy. At present, these minimally invasive techniques are subjected to clinical trials focusing on surgical outcome, quality of life, costs, long-term follow-up, and also morbidity of donor, recipient, and graft. In practice, many centers only perform donor nephrectomy on young healthy donors with normal weight. There is increasing evidence that donor nephrectomy with multiple arteries, right kidney and obese patients can be done with precaution. In this review, we address the surgical part of live kidney donation and the best level of evidence for all surgical techniques and issues surrounding the technique. © 2009 European Society for Organ Transplantation.




“Robot-assisted laparoscopic repair of renal artery aneurysms.”

Giulianotti, P. C., F. M. Bianco, et al. (2010).

Journal of Vascular Surgery.


Objective: The aim of this article is to report our experience in the repair of renal artery aneurysms using robot-assisted surgery. Methods: Between December 2002 and March 2009, five women with a mean age of 63.8 years (range, 57-78 years) underwent robot-assisted laparoscopic repair of renal artery aneurysms by the same surgeon at two different institutions, the Department of General Surgery, Misericordia Hospital, Grosseto, Italy (three patients) and the Division of Minimally Invasive and Robotic Surgery at the University of Illinois, Chicago (two patients). The mean size of the lesions was 19.4 mm (range, 9-28 mm). Four of the lesions were complex aneurysms involving the renal artery bifurcation. Two patients were symptomatic and three had hypertension. In situ repair by aneurysmectomy was performed in all cases, followed by revascularization. In complex aneurysms, an autologous saphenous vein graft was used for the reconstruction. Results: The mean operative time was 288 minutes (range, 170-360 min) and the estimated surgical blood loss was 100 ml (range, 50-300 ml). Warm ischemia time was 10 minutes in the patient treated by aneurysmectomy, followed by direct reconstruction. The average warm ischemia time was 38.5 minutes (range, 20-60 min) for patients treated with saphenous vein graft interposition. The mean time to resume a regular diet was 1.6 days (range, 1-2 days). The mean postoperative length of hospital stay was 5.6 days (range, 3-7 days). No postoperative morbidity was noted. The mean follow-up time for the entire series was 28 months (range, 6-48 months). Color Doppler ultrasonography examination showed patency in all reconstructed vessels. One patient had stenosis of one of the reconstructed branches, which was treated with percutaneous angioplasty. Conclusions: Robot-assisted laparoscopic repair of renal artery aneurysms is feasible, safe and effective. The technical advantages of the robotic system allows for microvascular reconstruction to be performed using a minimally invasive approach, even in complex cases. This approach may also allow for improved postoperative recovery and reduce the morbidity correlated with open repair of renal artery aneurysms. Although more experience and technical refinements are necessary, robot-assisted laparoscopic repair of renal artery aneurysms represents a valid alternative to open surgery.




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

Gong, Y., C. Du, et al. (2010).

World J Urol 28(1): 111-115.


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




“Robot-assisted partial nephrectomy: evaluation of learning curve for an experienced renal surgeon.”

Haseebuddin, M., B. M. Benway, et al. (2010).

J Endourol 24(1): 57-61.


PURPOSE: The learning curve for robot-assisted partial nephrectomy (RAPN) has not been extensively studied. We therefore evaluated the learning curve of RAPN for a fellowship-trained laparoscopic surgeon with extensive prior experience with laparoscopic partial nephrectomy (LPN). We also examined the potential effect of tumor size on the learning curve. PATIENTS AND METHODS: We prospectively evaluated 38 consecutive patients undergoing RAPN by a single surgeon (S.B.B.). Sixteen patients had tumors <2 cm, and 22 patients had tumors >2 cm. Warm ischemia times and overall operative times were recorded as indices of learning progression. RESULTS: Average operative time for tumors <2 cm was 131.9 minutes (115.3-148.5 minutes) and for tumors >2 cm was 145.8 minutes (131.1-160.5 minutes). The difference between the operative times for tumors <2 and >2 cm was not statistically significant (p = 0.23). Average warm ischemia time for tumors <2 cm was 21 minutes (16.9-25.1 minutes) and for tumors >2 cm was 24.7 minutes (21.3-28.1 minutes). This difference was also not statistically significant (p = 0.20). Defined by the overall operative time, the learning curve for RAPN was 16 cases, and by ischemic time, the learning curve was 26 cases. Tumor size did not have an effect on the learning curve. CONCLUSIONS: The learning curve for RAPN is short for surgeons already experienced with LPN. The learning curve for portions performed under warm ischemia is slightly longer, implying that the critical portions of the procedure require more experience to become facile. Tumor size does not appear to have a significant impact on the learning curve for surgeons experienced with LPN.




“Current status of nephron-sparing robotic partial nephrectomy.”

Hsieh, T. C., T. W. Jarrett, et al. (2010).

Curr Opin Urol 20(1): 65-69.


PURPOSE OF REVIEW: Partial nephrectomy has become the standard of treatment for renal tumors less than 4 cm in size. Recent reports have even applied this technique for T1b lesions as well. With advancement in minimally invasive techniques, laparoscopic and robotic surgeries are performed with the advantage of decreased morbidity while maintaining the same oncologic principles as those of open surgery. RECENT FINDINGS: Feasibility studies confirmed that robot-assisted partial nephrectomy can be performed safely. Short-term outcomes are similar to those of laparoscopic and open partial nephrectomy. Complex renal tumors, such as hilar and endophytic lesions, have also been performed robotically. SUMMARY: Robot-assisted partial nephrectomy is feasible with short-term results comparable to those of open and laparoscopic surgery. With challenges of pure laparoscopic surgery, robotic assistance may provide more opportunities for minimally invasive nephron-sparing surgery.




“Robot-assisted laparoscopic nephrectomy and contralateral ureteral reimplantation in children.”

Lee, R. S., A. S. Sethi, et al. (2010).

J Endourol 24(1): 123-128.


BACKGROUND: Robot-assisted laparoscopic surgery (RALS) has expanded the role for minimally invasive surgery within pediatrics. RALS may be particularly beneficial for the treatment of children with a refluxing nonfunctioning renal moiety and contralateral vesicoureteral reflux. In this report, we describe a single RALS procedure, which includes both nephrectomy or partial nephrectomy, and contralateral extravesical ureteral reimplantation (EVUR). METHODS: A retrospective review was performed of four patients who underwent RALS nephrectomy/partial nephrectomy and concurrent EVUR in one setting. Procedures were performed by a single surgeon using a robot-assisted laparoscopic approach. Four ports were used in a transperitoneal approach with patient positioning changed without moving the robotic system between the nephrectomy and reimplant. We described the technique and assessed its safety and efficacy. RESULTS: All cases were treated with the single RALS approach. Mean patient age was 2.3 years. Three patients underwent a nephrectomy and one a lower pole partial nephrectomy. The mean estimated blood loss was 16 mL, mean operative time was 291 minutes, and mean length of stay was 2.3 days. There was one case of postoperative ureteral obstruction that was treated with 3 weeks of ureteral stenting without further sequela. Overall, the mean follow-up time was 21 months and follow-up renal ultrasonographs and radionuclide cystograms were normal in all patients. CONCLUSIONS: A single RALS procedure that combines nephrectomy/partial nephrectomy and EVUR offers a novel approach to a clinical dilemma that often requires two operations. In this small series, RALS was safe and efficacious. We recommend routine Double-J stenting for the solitary reimplanted ureter.




“Robotic-assisted partial nephrectomy: Has it come of age.”

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

Indian Journal of Urology 25(4): 523-528.


Surgical resection is the gold standard for the treatment of renal cell carcinoma, and partial nephrectomy (PN) is the treatment of choice for tumors smaller than 4 cm in size. A laparoscopic PN is a viable alternative to a traditional open PN, demonstrating good oncologic and functional outcomes. A laparoscopic PN is a challenging procedure, particularly performing intracorporeal suturing under the time constraints of warm ischemia. The introduction of the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA) with wristed instruments and magnified, 3-dimensional vision may facilitate the technical challenges of a minimally invasive PN. The technique of robotic partial nephrectomy (RPN) is still evolving and a number of institutions have recently reported their results. In this article, we present a review of the literature and our technique for robotic PN using a transperitoneal approach.




“Robot-Assisted Management of Congenital Renal Abnormalities in Adult Patients.”

Patel, M. N., S. A. Kaul, et al. (2010).

J Endourol.


Abstract Introduction: Congenital anomalies of the genitourinary tract are usually diagnosed and corrected in childhood. Robot-assisted management of congenital urologic abnormalities in adult patients has not been described previously. We present a series of patients with congenital renal abnormalities diagnosed in adulthood and managed using a robotic approach. Methods: Four patients at our institution were identified with congenital renal abnormalities diagnosed in adulthood. One had a duplicated collecting system with hydronephrosis of a thinned out upper pole moiety and underwent heminephroureterectomy. A second had right hydronephrosis, complete atrophy of the right renal cortex, and a dilated tortuous ureter with obstructing ureterocele and underwent simple nephrectomy. A third patient had a duplicated system with distal ureteral reflux and an ureterocele and underwent ureteroureterostomy and distal ureterectomy. The fourth had a duplicated collecting system with ureterovaginal fistula of the upper pole moiety. Perioperative variables were collected including operative time, estimated blood loss, length of hospital stay, and change in estimated creatinine clearance. Results: Mean age was 35 years (range 16-54), mean body mass index was 30.9 kg/m(2) (21.8-42.5), and mean baseline estimated creatinine clearance was 147.7 mL/minutes (107.7-214.6). Mean operative time was 258 minutes (151-374) and mean estimated blood loss was 44 mL (25-50). Postoperative estimated creatinine clearance was 133.1 mL/minutes (115.9-160.9), which was not statistically different from preoperative values (p = 0.608). All patients were discharged by postoperative day 2. There were no perioperative complications. Conclusions: Robot-assisted management of congenital renal abnormalities is a feasible and efficacious treatment modality in adult patients with low morbidity and good outcomes.




“Robotic partial nephrectomy: A comparison to current techniques.”

Patel, M. N., M. Menon, et al. (2010).

Urologic Oncology: Seminars and Original Investigations 28(1): 74-76.


The bar has been set high for nephron sparing surgery by experts in both open and laparoscopic approaches. Robotic partial nephrectomy has emerged as an option for minimally invasive nephron sparing surgery. We discuss the current literature for robotic partial nephrectomy in the context of reported outcomes for open and laparoscopic partial nephrectomy. © 2010 Elsevier Inc. All rights reserved.




“Robot-assisted Partial Nephrectomy: A Large Single-institutional Experience.”

Scoll, B. J., R. G. Uzzo, et al. (2010).



Objectives: To report experience with 100 robot-assisted partial nephrectomy (RAPN) operations performed at our institution. Nephron-sparing surgery is an established treatment for patients with small renal masses. The laparoscopic approach has emerged as an alternative to open nephron-sparing surgery, but it is recognized to be technically challenging. The robotic surgical system may enable faster and greater technical proficiency, facilitating a minimally invasive approach to more difficult lesions while reducing ischemia time. Methods: A total of 100 RAPN operations were performed for suspicious solid renal lesions during a 21-month period. Clinicopathologic variables, nephrometry scores, operative parameters, and renal functional outcomes were prospectively recorded and analyzed. Results: Median tumor size was 2.8 cm (range, 1.0-8). Nephrometry scores of resected lesions were low in 47.9% of patients, medium in 45.7%, and high in 6.4% of patients. Forty-seven percent of patients had tumors &gt;50% intraparenchymal, and 61.7% had tumors located less than 7 mm away from the renal sinus or collecting system. In 17% of patients, the tumors were touching a first-order vessel in the renal hilum. Mean warm ischemia time was 25.5 minutes (range, 0-53). Mean change in postoperative glomerular filtration rate improved 6.32 mL/min/1.73 m<sup>2</sup> (range, -41.9 to 68.9). Histology was renal cell carcinoma in 81% (87/107) of tumors. There were 5 microscopically positive margins on final pathology (5.7%). Major and minor complication rates were 6% and 5%, respectively. There were 2 conversions to open surgery. Conclusions: RAPN seems to be a safe and technically feasible minimally invasive approach to nephron-sparing surgery even in more complex cases, with acceptable pathologic and renal function outcomes. © 2009 Elsevier Inc. All rights reserved.




“Robotic suture of a large caval injury caused by endo-GIA stapler malfunction during laparoscopic wedge resection of liver segments VII and VIII en-bloc with the right hepatic vein.”

Boggi, U., C. Moretto, et al. (2009).

Minimally Invasive Therapy and Allied Technologies 18(5): 306-310.


Primary endo-GIA stapler malfunction occurred during robotic wedge resection of liver segments VII and VIII en-bloc with the right hepatic vein, in an obese woman diagnosed with single liver metastasis from a previous carcinoid tumour. Haemorrhage was soon controlled by clamping the vena cava below the injury using two wristed forceps angled at 90°. With the two instruments locked in the holding position the ensuing operative strategy was discussed between surgeon and anaesthesia teams. Using the third robotic arm the caval injury was repaired laparoscopically with interrupted polypropylene sutures. The patient was transfused with two units of packed red blood cells, recovered uneventfully, and was discharged on post-operative day five. We conclude that even the most advanced technologies can fail and that surgeons should be fully aware of the consequences of these malfunctions and be prepared for repair. From this point of view, the da Vinci surgical system seems to have some advantages over classical laparoscopic methods including the ability to lock the wristed instruments in the holding position, the use of three arms by the same operating surgeon, and the extreme facilitation of intracorporeal suturing and knot-tying in deep and narrow spaces, extremely difficult if not impossible with conventional laparoscopic instruments. © 2009 Informa UK Ltd.




“Robotic-assisted laparoscopic surgery in pediatric urology: An update.”

Casale, P. and Y. Kojima (2009).

Scandinavian Journal of Surgery 98(2): 110-119.


Laparoscopic procedures for urological diseases in children, such as nephrectomy, pyeloplasty and orchiopexy, have proven to be safe and effective with outcome comparable to the open procedure. However, main drawback has been the relatively steep learning curve for this procedure because of technical difficulties of suturing and anastomosis. More recently, robotic-assisted laparoscopic surgery (RAS) has gained enormous popularity in adult urology and is increasingly being adopted around the world; however, few pediatric urology series have been reported. RAS has several advantages over conventional laparoscopic surgery, with the main advantage being simplification and precision of exposure and suturing because of allowing movements of the robotic arm in real time with increased degree of freedom and magnified 3-dimentional view. These features render RAS ideal for complex reconstructive surgery in a pediatric urological population. This review discusses the role of RAS in pediatric urology, and provides some technical aspects of RAS and a critical summary of current knowledge on its indications and outcome. Almost all operations that are classically performed as open or conventional laparoscopic reconstructive surgery for children with urological anomalies could be replaced by RAS, which may be established as an alternative minimally invasive surgery in the future.




“Telementoring and Telerobotics in Urological Surgery.”

Challacombe, B. and S. Wheatstone (2010).

Current Urology Reports: 1-7.


For more than 150 years, doctors have had the ability to transmit medical information to advise and assist their colleagues in remote locations via teleconsultation using a variety of communication modalities. In surgery this has evolved into the telementoring of minimally invasive procedures, particularly, robotic surgery, which have become relatively commonplace in urology. The ultimate progression to true telerobotic surgery, in which remote surgeons independently perform complex and fundamental parts of procedures at long range, is starting to occur. This article discusses the current state of telementoring and telerobotics in urology and examines the pros and cons of this technology at the present time. © 2010 Springer Science+Business Media, LLC.




“Robotic urological surgery: consideration for the future.”

Crouzet, S. and G. P. Haber (2009).

Les nouvelles pistes de la chirurgie robotique en urologie 19(3).


Robotic surgery is an expanding field. Recent advances in surgical navigation and in mini-invasive approach open new perspectives for the use of robotics in urology. Single port and NOTES could support new developments for the DaVinci robotic system. New technologies such as articulated tools, 3D vision, lasers and mini-invasive approach could meet robotics in clever convenient associations. Robotised needle holders and ureteroscopes are new applications and « intelligent » multifunction tools open an new era. The concept of biosurgery together with microrobots trigger new attempts at miniaturization. © 2009.




“Robot-assisted laparoscopic urologic surgery.”

Lasser, M. S., L. Cheuck, et al. (2009).

Medicine and health, Rhode Island 92(10): 327-330.




“Economics of robotics in urology.”

Lotan, Y. (2010).

Curr Opin Urol 20(1): 92-97.


PURPOSE OF REVIEW: New technologies such as robotics are constantly introduced clinically without a complete understanding of benefits and costs. In order for urologists to optimize their care of patients, there is a need to understand the economic factors that impact on their ability to practice medicine. This review will discuss general concepts of health economics and apply them to the application of robotics to urologic procedures. RECENT FINDINGS: Utilization of robotic surgery, especially for robotic-assisted laparoscopic prostatectomy, has increased dramatically in recent years. The robot adds significant costs in terms of acquisition, maintenance, and daily instrument costs. These added costs, thus far, have not been associated with significant improvement in outcomes over ‘pure’ laparoscopy or open procedures. In order for the robot to be cost-effective, efficacy needs to be improved over alternative approaches and costs of the robot or instrumentation needs to be decreased. SUMMARY: Robotic application is not cost-effective compared with open or laparoscopic approaches and future studies will need to determine whether there are indirect benefits that will justify its use.




“The role of minimally invasive urology in the new millennium.”

Pareek, G. (2009).

Medicine and health, Rhode Island 92(10): 324.




“Robotic surgery in male infertility and chronic orchialgia.”

Parekattil, S. J. and M. S. Cohen (2010).

Curr Opin Urol 20(1): 75-79.


PURPOSE OF REVIEW: The use of robotic assistance during microsurgical procedures is currently being explored in the treatment of male infertility and patients with chronic testicular pain. Whether the addition of this technology would allow a corresponding improvement in outcomes as when the operating microscope was introduced in microsurgery is yet to be seen. RECENT FINDINGS: The present review covers new robotic microsurgical tools and applications of the robotic platform in microsurgical procedures such as vasectomy reversal, varicocelectomy, denervation of the spermatic cord for chronic testicular pain and microsurgical vascular anastomosis. Preliminary animal studies appear to show an advantage in terms of improved operative efficiency and improved surgical outcomes. Preliminary human clinical studies appear to support these findings. The use of robotic assistance during robotic microsurgical vasovasostomy appears to decrease operative duration and significantly improve early postoperative sperm counts compared with the pure microsurgical technique. SUMMARY: As with any new technology, long-term prospective controlled trials are necessary to assess the true cost-benefit ratio for robotic assisted microsurgery. The preliminary findings are promising, but further evaluation is warranted.




“A unique instrumental malfunction during robotic prostatectomy.”

Park, S. Y., J. J. Ahn, et al. (2010).




“The history of robotics in urology.”

Patel, S. R. and G. Pareek (2009).

Medicine and health, Rhode Island 92(10): 325-326.




“Building a robotic program.”

Rocco, B., A. Lorusso, et al. (2009).

Scandinavian Journal of Surgery 98(2): 72-75.




“The current status of robot-assisted laparoscopic prostatectomy.”

Altamar, H. O. and S. D. Herrell (2010).

Curr Opin Urol 20(1): 56-59.


PURPOSE OF REVIEW: To review the recent urologic literature with a focus on refinements of surgical technique in robot-assisted laparoscopic prostatectomy (RALP) and to discuss the impact of these developments on the ‘trifecta’ of prostate cancer management: oncologic, continence, and potency outcomes. RECENT FINDINGS: Refinements in the surgical technique during the established steps of radical prostatectomy have led to improved functional outcomes following RALP. Early continence rates have increased, and potency, with evolving respect for the neurovascular bundle and neural anatomy, has further promise. ‘Long-term’ outcomes demonstrate favorable results in continence and potency. Oncologic outcomes, specifically low positive margin rates, have been maintained and even improved in many series during the evolution of this widely accepted procedure. SUMMARY: RALP has continued to rapidly disseminate through the urologic community, but the ultimate impact remains under scrutiny. The procedure has seen birth from open and laparoscopic prostatectomy, and its success has been measured against contemporary open prostatectomy series during its infancy. Short and long-term oncologic outcomes must be followed carefully. The assessment of functional outcomes of continence and potency requires honest and, as best possible, objective analysis. Prospective, randomized clinical trials with long-term follow-up utilizing validated instruments are necessary to evaluate RALP and all associated technical modifications.




“Robotic Assisted Laparoscopic Prostatectomy Versus Radical Retropubic Prostatectomy for Clinically Localized Prostate Cancer: Comparison of Short-Term Biochemical Recurrence-Free Survival.”

Barocas, D. A., S. Salem, et al. (2010).

Journal of Urology.


Purpose: We compared biochemical recurrence-free survival of patients who underwent radical retropubic prostatectomy vs robot assisted laparoscopic prostatectomy in concurrent series at a single institution. Materials and Methods: A total of 2,132 patients were treated between June 2003 and January 2008. We excluded from study patients with prior treatment (115), missing data (83) and lymph node involvement (30). The remaining cohort (1,904) was compared based on clinical, surgical and pathological factors. Kaplan-Meier analysis was performed comparing biochemical recurrence after robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy. A Cox proportional hazards model was generated to determine whether surgical approach is an independent predictor of biochemical recurrence. Results: There were 491 radical retropubic prostatectomies (25.9%) and 1,413 robot assisted laparoscopic prostatectomies (74.1%) performed, and median followup was 10 months (IQR 2 to 23). On univariate analysis the robot assisted laparoscopic prostatectomy group was slightly lower risk with lower median prostate specific antigen (5.4 vs 5.8, p <0.01), a lower proportion of pathological grade 7-10 (48.5% vs 54.7%, p <0.01) and lower pathological stage (80.5% pT2 vs 69.6% pT2, p <0.01). The 3-year biochemical recurrence-free survival rate was similar between the robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy groups on the whole as well as when stratified by pathological stage, grade and margin status. On multivariate analysis extracapsular extension (p <0.01), pathological grade 7 or greater (p <0.01) and positive surgical margin (p <0.01) were independent predictors of biochemical recurrence while surgical approach was not. Conclusions: The likelihood of biochemical recurrence was similar between groups when stratified by known risk factors of recurrence. Surgical approach was not a significant predictor of biochemical recurrence in the multivariate model. Our analysis is suggestive of comparable effectiveness for robot assisted laparoscopic prostatectomy, although longer term studies are needed. © 2010 American Urological Association Education and Research, Inc.




“The incidence and anatomy of accessory pudendal arteries as depicted on multidetector-row CT angiography: Clinical implications of preoperative evaluation for laparoscopic and robot-assisted radical prostatectomy.”

Beom, J. P., J. S. Deuk, et al. (2009).

Korean Journal of Radiology 10(6): 587-595.


Objective: To help preserve accessory pudendal arteries (APAs) and to ensure optimal postoperative sexual function after a laparoscopic or robot-assisted radical prostatectomy, we have evaluated the incidence of APAs as detected on multidetector-row CT (MDCT) angiography and have provided a detailed anatomical description. Materials and Methods: The distribution of APAs was evaluated in 121 consecutive male patients between February 2006 and July 2007 who underwent 64-channel MDCT angiography of the lower extremities. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex. We also subclassified APAs into lateral and apical APAs. Two radiologists retrospectively evaluated the origin, course and number of APAs; the final APA subclassification based on MDCT angiography source data was determined by consensus. Results: We identified 44 APAs in 36 of 121 patients (30%). Two distinct varieties of APAs were identified. Thirty-three APAs (75%) coursed near the anterolateral region of the prostatic apex, termed apical APAs. The remaining 11 APAs (25%) coursed along the lateral aspect of the prostate, termed lateral APAs. All APAs originated from the internal obturator artery and iliac artery or a branch of the iliac artery such as the inferior vesical artery. The majority of apical APAs arose from the internal obturator artery (84%). Seven patients (19%) had multiple APAs. Conclusion: APAs are more frequently detected by the use of MDCT angiography than as suggested by previous surgical studies. The identification of APAs on MDCT angiography may provide useful information for the surgical preservation of APAs during a laparoscopic or robot-assisted radical prostatectomy.




“Robotic-assisted radical prostatectomy.”

Bladou, F. and J. Walz (2009).

Prostatectomie totale robot-assistée 19(SUPPL. 4).


The beginning of the 21rst century have ushered the new era of robotic surgery that now challenges conventional open surgery. Robotic surgery has been embraced by urologists who have applied it to complex surgical procedures such as radical prostatectomy. The revolutionary improvements provided by the Da Vinci Surgical System<sup>®</sup> combines superior 3D visualization along with enhanced dexterity such as the endowrist allowing distal supranatural rotation of instruments, precision and control in an intuitive, ergonomic interface with breakthrough surgical dissection and suturing capabilities in confined spaces. Da Vinci Surgical System<sup>®</sup> allows to perform nerve sparing radical prostatectomy techniques in various surgical plans (inter, intra and extrafascial) with a shorter learning curve and probably outcomes more rapidly reproducible by a less experienced laparoscopic surgeon. © 2009 Elsevier Masson SAS. All rights reserved.




“Sacrifice of accessory pudendal arteries in normally potent men during robot-assisted radical prostatectomy does not impact potency.”

Box, G. N., A. G. Kaplan, et al. (2010).

Journal of Sexual Medicine 7(1 PART 1): 298-303.


Aim: Whether or not sacrificing accessory pudendal arteries (APAs) during radical prostatectomy affects potency has been an ongoing source of concern. Herein, we present our potency results relative to sacrificing APAs in normally pre-potent men following robot-assisted radical prostatectomy (RARP). Methods: The distribution of APAs and clinical characteristics were prospectively recorded in 200 consecutive patients undergoing RARP with a cautery-free technique. Sexual function was assessed using the International Index of Erectile Function 5-item questionnaire (IIEF-5). All APAs were sacrificed due to stapling the dorsal vein complex. Main Outcome Measures: Postoperatively, potency was defined by an affirmative answer to the following two questions: ” Were erections adequate for penetration?” and ” were the erections satisfactory?” Postoperative IIEF-5 scores and quality of erections (% of preoperative firmness: 0%, 25%, 50%, 75%, 100%) were also obtained. Subgroup analysis of patients age ≤65 years with IIEF-5 score of 22-25 was performed. Results: Eighty patients (40%) had APAs. Preoperatively, there was no association with having an APA and normal/abnormal sexual function. Preoperatively, 58/200 were ≤65 years with self-administered IIEF-5 scores of 22-25. Postoperatively, 53/58 (91%) were potent at 24 months follow-up. Nineteen of 58 patients had a sacrificed APA; 39 patients had no APA. Eighteen of 19 (95%) patients with sacrificed APAs were potent vs. 35/39 (90%) with no APA present (P = 0.53). Multivariate analysis showed no significant correlation between sacrificing an APA and time of potency recovery, quality of postoperative erections (94% vs. 90% P = 0.80) or mean IIEF-5 score (22.4 vs. 20.8, P = 0.13). Conclusion: We found no correlation between the presence or absence of APAs and preoperative sexual function. Furthermore, after sacrificing all APAs, we found no correlation with potency return, time to return of potency, quality of erections, or mean IIEF-5 scores at 24 months. © 2009 International Society for Sexual Medicine.




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

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

Current Prostate Reports 7(3): 102-108.


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




“Robotic Assisted Laparoscopic Prostatectomy versus Laparoscopic Assisted Prostatectomy: A Financial Analysis.”

Chatterjee, A., L. Chen, et al. (2010).

J Surg Res 158(2): 380.




“Biopsy related prostate status does not affect on the clinicopathological outcome of robotic assisted laparoscopic radical prostatectomy.”

Choi, H., Y. H. Ko, et al. (2009).

Cancer Res Treat 41(4): 205-210.


PURPOSE: To determine whether the biopsy core number and time interval between prostate biopsy and radical prostatectomy affect the operative and oncologic outcome of robot assisted laparoscopic radical prostatectomy (RALP). MATERIALS AND METHODS: From January 2008 to April 2009, a single surgeon performed 72 RALPs after an initial learning period of 30 cases. The relationship between time from biopsy to prostatectomy and biopsy core number with operative time and estimated blood loss (EBL) were initially evaluated with a linear regression model. These patients were classified into groups according to whether the interval from biopsy to RALP was within four weeks or not, and whether there were less than or greater than 10 core specimens removed. RESULTS: RALP was performed in 34 patients within four weeks of biopsy, and in 38 patients more than 4 weeks after biopsy. According to the number of core specimens removed, less than 10 cores were performed in 10 patients, and more than 10 cores were performed in 62 patients. Using an interval of 4 weeks as the cutoff point, early surgery was associated with longer operating time (232.6 vs 208.8 min) and increased estimated blood loss (305.1 vs 276.9 mL). For cases with more than 10 biopsy cores, there was a slight increase in operative time (229.2 vs 210.3 min). None of these differences were statistically significant by multivariate analysis. CONCLUSION: Our data suggests that there is no reason to delay RALP to more than 4 weeks after prostate biopsy. It also revealed that the number of biopsy cores (up to 14) did not influence operative outcome. Thus, RALP is a feasible procedure regardless of the biopsy related prostate state.




“Should experienced open prostatic surgeons convert to robotic surgery? The real learning curve for one surgeon over 3 years.”

Doumerc, N., C. Yuen, et al. (2010).

BJU Int.


Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To critically analyse the learning curve for one experienced open surgeon converting to robotic surgery for radical prostatectomy (RP). PATIENTS AND METHODS From February 2006 to December 2008, 502 patients had retropubic RP (RRP) while concurrently 212 had robot-assisted laparoscopic RP (RALP) by one urologist. We prospectively compared the baseline patient and tumour characteristics, variables during and after RP, histopathological features and early urinary functional outcomes in the two groups. RESULTS The patients in both groups were similar in age, preoperative prostate-specific antigen level, and prostatic volume. However, there were more high-stage (T2b and T3, P= 0.02) and -grade (Gleason 9, P= 0.01) tumours in the RRP group. The mean (range) operative duration was 147 (75-330) min for RRP and 192 (119-525) min for RALP (P < 0.001); 110 cases were required to achieve ’3-h proficiency’. Major complication rates were 1.8% and 0.8% for RALP and RRP, respectively. The overall positive surgical margin (PSM) rate was 21.2% in the RALP and 16.7% in the RRP group (P= 0.18). PSM rates for pT2 were comparable (11.6% vs 10.1%, P= 0.74). pT3 PSM rates were higher for RALP than RRP (40.5% vs 28.8%, P= 0.004). The learning curve started to plateau in the overall PSM rate after 150 cases. For the pT2 and pT3 PSM rates, the learning curve tended to flatten after 140 and 170 cases, respectively. The early continence rates were comparable (P= 0.07) but showed a statistically significant improvement after 200 cases. CONCLUSIONS Our analysis of the learning curve has shown that certain components of the curve for an experienced open surgeon transferring skills to the robotic platform take different times. We suggest that patient selection is guided by these milestones, to maximize oncological outcomes.




“Quality of life after localized prostate cancer treatment.”

Droupy, S. (2009).

Qualité de vie après traitement du cancer de la prostate localisé 19(SUPPL. 4).


Patients treated for a prostate cancer and their partners agree to classify importance of quality of life domains as follow: first sexual life, vitality, irritative and obstructive urinary tract symptoms, urinary incontinence and bowel function. Each first line treatment of prostate cancer (radiotherapy, brachytherapy and surgery) is responsible for a specific quality of life domains modification profile. It is very difficult to predict, for a given patient, the importance of the sequellae and their perception by the patient and the partner. Information, prevention and early treatment of the sequellae allow improving quality of life. © 2009 Elsevier Masson SAS. All rights reserved.




“An Update of the Gleason Grading System.”

Epstein, J. I. (2010).

Journal of Urology 183(2): 433-440.


Purpose: An update is provided of the Gleason grading system, which has evolved significantly since its initial description. Materials and Methods: A search was performed using the MEDLINE® database and referenced lists of relevant studies to obtain articles concerning changes to the Gleason grading system. Results: Since the introduction of the Gleason grading system more than 40 years ago many aspects of prostate cancer have changed, including prostate specific antigen testing, transrectal ultrasound guided prostate needle biopsy with greater sampling, immunohistochemistry for basal cells that changed the classification of prostate cancer and new prostate cancer variants. The system was updated at a 2005 consensus conference of international experts in urological pathology, under the auspices of the International Society of Urological Pathology. Gleason score 2-4 should rarely if ever be diagnosed on needle biopsy, certain patterns (ie poorly formed glands) originally considered Gleason pattern 3 are now considered Gleason pattern 4 and all cribriform cancer should be graded pattern 4. The grading of variants and subtypes of acinar adenocarcinoma of the prostate, including cancer with vacuoles, foamy gland carcinoma, ductal adenocarcinoma, pseudohyperplastic carcinoma and small cell carcinoma have also been modified. Other recent issues include reporting secondary patterns of lower and higher grades when present to a limited extent, and commenting on tertiary grade patterns which differ depending on whether the specimen is from needle biopsy or radical prostatectomy. Whereas there is little debate on the definition of tertiary pattern on needle biopsy, this issue is controversial in radical prostatectomy specimens. Although tertiary Gleason patterns are typically added to pathology reports, they are routinely omitted in practice since there is no simple way to incorporate them in predictive nomograms/tables, research studies and patient counseling. Thus, a modified radical prostatectomy Gleason scoring system was recently proposed to incorporate tertiary Gleason patterns in an intuitive fashion. For needle biopsy with different cores showing different grades, the current recommendation is to report the grades of each core separately, whereby the highest grade tumor is selected as the grade of the entire case to determine treatment, regardless of the percent involvement. After the 2005 consensus conference several studies confirmed the superiority of the modified Gleason system as well as its impact on urological practice. Conclusions: It is remarkable that nearly 40 years after its inception the Gleason grading system remains one of the most powerful prognostic factors for prostate cancer. This system has remained timely because of gradual adaptations by urological pathologists to accommodate the changing practice of medicine. © 2010 American Urological Association.




“Quantitative and qualitative analysis of the recovery of potency after radical prostatectomy: Effect of unilateral vs bilateral nerve sparing.”

Finley, D. S., E. Rodriguez Jr, et al. (2009).

BJU International 104(10): 1484-1489.


OBJECTIVES To analyse the impact of a ≈50% reduction of cavernous nervous tissue on the qualitative and quantitative recovery of sexual function after unilateral (UNS) and bilateral (BNS) nerve-sparing robotic radical prostatectomy (RALP), by evaluating these differences in two groups treated with cautery and a cautery-free technique (CFT). PATIENTS AND METHODS UNS was defined as wide-excision of one neurovascular bundle (NVB). Only men aged ≤65 years with preoperative International Index of Erectile Function (IIEF-5) scores of ≥22 were included. The cautery group comprised 42 men (of case numbers 1-125) undergoing RALP with cautery, and the CFT group (62 men of cases 151-350) had a cautery-free technique along the NVB. Data were collected prospectively using validated self-administered questionnaires. Potency was defined as two affirmative answers to: do you have erections ‘adequate for vaginal penetration?’ and ‘Are they satisfactory?’. Patient-reported IIEF-5 scores and quality of erections (i.e. an estimate of erection as 0%, 25%, 50%, 75% or 100% of preoperative fullness) were obtained after surgery. RESULTS In the cautery group, doubling the nerve volume increased potency by 1.36 times (UNS 50% vs BNS 68%). The results were similar in the CFT group as doubling nerve tissue increased potency by 1.15 times (UNS 80% and BNS 93%). At 24 months, comparing IIEF-5 scores, there was no difference between UNS and BNS for the cautery group, at 19.6 (95% confidence interval 15.7-23.5) vs 18.9 (16.6-21.0), or the CFT group, at 22.0 (20.2-23.8) vs 21.0 (19.8-22.1). CONCLUSIONS Doubling the nerve volume only increased potency by 1.15-1.36 times for both the CFT and cautery groups. Furthermore, the quality of erections and IIEF-5 scores did not vary appreciably with doubling of nerve tissue. © 2009 BJU International.




“”Learning Curve” May Not Be Enough: Assessing the Oncological Experience Curve for Robotic Radical Prostatectomy.”

Hong, Y. M., D. E. Sutherland, et al. (2010).

J Endourol.


Abstract The use of robot-assisted laparoscopic radical prostatectomy (RALP) is widespread in the community. A definitive RALP “learning curve” has not been defined and existing learning curves do not account for urologists without prior advanced laparoscopic skills. Therefore, an easily evaluable metric, the “oncological experience curve,” would be clinically useful to all urologists performing RALP. Positive surgical margin (PSM) status for all subjects undergoing RALP during the first 4 years of a single surgeon’s experience was assessed. Univariate and multivariate analyses and logistic regression identified predictors of PSM creation and their correlation with surgeon case volume. The oncological experience curve was defined as the case point at which only pT2 stage, not surgeon volume (and thus surgeon inexperience), predicted PSM in the logistic regression. A total of 469 consecutive subjects comprised our cohort. Overall pT2 and pT3 PSM rates were 20% and 40%, respectively. Preoperative prostate-specific antigen, pathologic stage, and year of surgery were associated with PSM occurrence. Pathologic stage exclusively correlated to PSM in pT2 specimens for the first time during the fourth year, after 290 subjects had been treated. pT2 PSM rate before and after Case 290 was 25% and 10%, respectively (p < 0.001). The oncological experience curve is a clinically meaningful measure to evaluate the RALP learning curve for non-fellowship-trained urologists. The oncological experience curve may be much longer than the previously reported learning curves. Surgeons should consider whether they can build enough experience to minimize suboptimal oncological outcomes before embarking on or continuing a RALP program.




“Laparoscopic radical prostatectomy versus robot-assisted laparoscopic radical prostatectomy: A single surgeon’s experience.”

Jae, W. C., H. K. Tae, et al. (2009).

Korean Journal of Urology 50(12): 1198-1202.


Purpose: We compared a single surgeon’s experience with radical prostatectomy by laparoscopic radical prostatectomy (LRP) versus robot-assisted laparoscopic radical prostatectomy (RARP) with regard to preoperative, intraoperative, and postoperative parameters. Materials and Methods: We retrospectively reviewed 120 patients undergoing LRP and RARP from January 2003 to December 2008. The patients were matched for age, body mass index, prostate-specific antigen, pathological stage, and Gleason score. Preoperative, perioperative, and postoperative data, including complications, and trifecta results (positive surgical margin, potency, and continence) were analyzed between the two groups. Results: The two groups were statistically similar with respect to age, body mass index, prostate-specific antigen, Gleason score, and clinical stage. The RARP group showed better results in operative time, estimated blood loss, hospital stay, and bladder catheterization duration. There were no major complications, but minor complications occurred in 25.0% versus 10.0% cases. The trifecta results were better in the RARP group than in the LRP group. Conclusions: RARP showed excellent results in several operative parameters compared with LRP. If the economic hurdle to RARP can be overcome, it will become the standard treatment in radical prostatectomy. ©The Korean Urological Association, 2009.




“Converting from open to robotic prostatectomy: Key concepts.”

Johnson, E. K. and D. P. Wood Jr (2010).

Urologic Oncology: Seminars and Original Investigations 28(1): 77-80.


Robotic-assisted laparoscopic prostatectomy (RALP) is rapidly becoming the surgical procedure of choice for treating localized prostate cancer. Although a learning curve does exist, RALP can readily be adopted by surgeons with minimal training in laparoscopy. Monitoring short- and long-term patient outcomes is the key to the individual surgeon improving this procedure for his/her patients. Although both open radical prostatectomy (ORP) and RALP can provide excellent patient outcomes, recent trends indicate that demand for RALP will continue to increase, and it is in the interest of the open surgeon to adopt this technique and aim to continuously improve patient outcomes after RALP. © 2010 Elsevier Inc. All rights reserved.




“Technique for urethral eversion and vesico-urethral anastomosis: Application to robot-assisted laparoscopic prostatectomy: Surgery Illustrated – Focus on Details.”

Karim, O., E. Mayer, et al. (2010).

BJU International 105(2): 284-287.




“Lymph node dissection during robotic-assisted laparoscopic prostatectomy: comparison of lymph node yield and clinical outcomes when including common iliac nodes with standard template dissection.”

Katz, D. J., D. S. Yee, et al. (2010).

BJU Int.


Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To compare the perioperative outcomes of standard pelvic to full-template lymph node (LN) dissection (LND) during robotic-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS The study included 94 patients undergoing RALP with LND between January 2007 and August 2008, by one surgeon. In February 2008 the LND template was modified to include common iliac and medial hypogastric LNs. Clinical and pathological patient characteristics were analysed, including total number of retrieved and positive LNs in each area of dissection, operative duration and complications. RESULTS Of the 94 patients, 62 underwent standard LND (group 1) and 32 underwent full-template pelvic LND (group 2). The median (mean) number of LNs retrieved in groups 1 and 2 were 12 (13.3) and 17.5 (21.4), respectively. Of the five patients with positive LNs (5%), four were in group 2 (13%); two of these patients had positive LNs in the common iliac dissection, and for one of these patients it was the sole site of involvement. Deep venous thrombosis, pulmonary embolism or transient neuropraxia occurred in six patients (five in group 1 and one in group 2). The median additional operative time for resection of common and internal LNs was 25 min. CONCLUSIONS LN yield increased and additional sites of LN metastases were identified during full-template pelvic LND during RALP. This modification was not associated with an increased rate of complications. Derived benefits of including additional nodal dissection and the effect on staging accuracy remain to be determined.




“Robot-assisted laparoscopic radical prostatectomy after previous cancer surgery.”

Kim, K. H., E. I. S. Lorenzo, et al. (2010).

Journal of Robotic Surgery: 1-5.


Robot-assisted laparoscopic radical prostatectomy has become a frequently used alternative treatment option in the management of prostate cancer. As more operations are performed, more challenging patient conditions are encountered, for example those with previous abdominal cancer surgery. We present our experience of robot-assisted laparoscopic radical prostatectomy (RALP) in patients with previous cancer surgery. Seven patients with a history of previous surgery for malignancy underwent RALP. All the prostatectomies were performed using the da VinciTM S surgical system by a single surgeon. All operations were approached transperitoneally. We reviewed perioperative data and surgical outcomes retrospectively. The mean age at surgery was 68.43 years (range 63-82). The mean operative time was 214 ± 47.32 min, and the median estimated blood loss was 500 ml (range 200-1,300). The mean hospital stay was 6.57 ± 2.15 days, and the mean duration of catheterization was 8.29 ± 3.09 days. Nerve-sparing procedure and pelvic lymph node dissection were performed in six patients. Rectal injury occurred in one patient who had undergone hemi-colectomy 15 years previously and was resolved by primary closure. Positive surgical margin was found in three patients. Although one patient had an intraoperative rectal injury, RALP in a patient with previous cancer surgery seems to be feasible and safe in experienced hands. © 2010 Springer-Verlag London Ltd.




“Current salvage methods for recurrent prostate cancer after failure of primary radiotherapy.”

Kimura, M., V. Mouraviev, et al. (2010).

BJU International 105(2): 191-201.


We reviewed the current salvage methods for patients with local recurrent prostate cancer after primary radiotherapy (RT), using a search of relevant Medline/PubMed articles published from 1982 to 2008, with the following search terms: ‘radiorecurrent prostate cancer, local salvage treatment, salvage radical prostatectomy (RP), salvage cryoablation, salvage brachytherapy, salvage high-intensity focused ultrasound (HIFU)’, and permutations of the above. Only articles written in English were included. The objectives of this review were to analyse the eligibility criteria for careful selection of appropriate patients and to evaluate the oncological results and complications for each method. There are four whole-gland re-treatment options (salvage RP, salvage cryoablation, salvage brachytherapy, salvage HIFU) for RT failure, although others might be in development or investigations. Salvage RP has the longest follow-up with acceptable oncological results, but it is a challenging technique with a high complication rate. Salvage cryoablation is a feasible option, especially using third-generation technology, whereby the average biochemical disease-free survival rate is 50-70% and there are fewer occurrences of severe complications such as recto-urethral fistula. Salvage brachytherapy, with short-term cancer control, is comparable to other salvage methods but depends on cumulative dosage limitation to target tissues. HIFU is a relatively recent option in the salvage setting. Both salvage brachytherapy and HIFU require more detailed studies with intermediate and long-term follow-up. As these are not prospective, randomized studies and the definitions of biochemical failure varied, there are limited comparisons among these different salvage methods, including efficacy. In the focal therapy salvage setting, the increased use of thermoablative methods for eligible patients might contribute to reducing complications and maintaining quality of life. The problem to effectively salvage patients with locally recurrent disease after RT is the lack of diagnostic examinations with sufficient sensitivity and specificity to detect local recurrence at an early curable stage. Therefore, a more strict definition of biochemical failure, improved imaging techniques, and accurate specimen mapping are needed as diagnostic tools. Furthermore, universal selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine which provides the best oncological efficacy and least comorbidity. © 2009 BJU International.




“Rapid Implementation of a Robot-Assisted Prostatectomy Program in a Large Health Maintenance Organization Setting.”

Kwon, E. O., T. C. Bautista, et al. (2010).

J Endourol.


Abstract Purpose: We present the rapid implementation of a robot-assisted surgery program by one of the largest health maintenance organizations (HMOs) in the United States. Materials and Methods: A core group of 10 urologists were offered access to a new da Vinci S surgical system. A core group of five ancillary staff was assembled and trained at an Intuitive Surgical-designated training site. An experienced robotic surgeon acted as a proctor. Data regarding patient demographics, preoperative parameters, operative times, pathologic outcomes, and EPIC-26 quality-of-life questionnaires were collected prospectively and reviewed. All procedures were recorded on digital video disc as part of a quality assurance protocol. The core group reviewed complications monthly and received feedback on surgical techniques and pathologic outcomes. Results: A total of 100 robot-assisted laparoscopic radical prostatectomies were performed from August to October 2008. The patient demographics, preoperative parameters, operative times, and pathologic outcomes of these first 100 procedures are outlined. Conclusions: We demonstrate the rapid implementation of an efficient multisurgeon HMO-based robot-assisted prostatectomy program with promising initial outcomes.




“Downsides of Robot-assisted Laparoscopic Radical Prostatectomy: Limitations and Complications.”

Murphy, D. G., A. Bjartell, et al. (2010).

European Urology.


Context: Robot-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is now in widespread use for the management of localised prostate cancer (PCa). Many reports of the safety and efficacy of this procedure have been published. However, there are few specific reports of the limitations and complications of RALP. Objective: The primary purpose of this review is to ascertain the downsides of RALP by focusing on complications and limitations of this approach. Evidence acquisition: A Medline search of the English-language literature was performed to identify all papers published since 2001 relating to RALP. Papers providing data on technical failures, complications, learning curve, or other downsides of RALP were considered. Of 412 papers identified, 68 were selected for review based on their relevance to the objective of this paper. Evidence synthesis: RALP has the following principal downsides: (1) device failure occurs in 0.2-0.4% of cases; (2) assessment of functional outcome is unsatisfactory because of nonstandardised assessment techniques; (3) overall complication rates of RALP are low, although higher rates are noted when complications are reported using a standardised system; (4) long-term oncologic data and data on high-risk PCa are limited; (5) a steep learning curve exists, and although acceptable operative times can be achieved in <20 cases, positive surgical margin (PSM) rates may require experience with >80 cases before a plateau is achieved; (6) robotic assistance does not reduce the difficulty associated with obese patients and those with large prostates, middle lobes, or previous surgery, in whom outcomes are less satisfactory than in patients without such factors; (7) economic barriers prevent uniform dissemination of robotic technology. Conclusions: Many of the downsides of RALP identified in this paper can be addressed with longer-term data and more widespread adoption of standardised reporting measures. The significant learning curve should not be understated, and the expense of this technology continues to restrict access for many patients. © 2009 European Association of Urology.




“Evolution of robot-assisted radical prostatectomy.”

Orvieto, M. A. and V. R. Patel (2009).

Scandinavian Journal of Surgery 98(2): 76-88.


Introduction and Objective: Open radical prostatectomy (RRP) is the gold standard and most widespread treatment for clinically localized prostate cancer. However, in recent years robot-assisted laparoscopic prostatectomy (RARP) is rapidly gaining acceptance among urologists worldwide. We sought to outline our surgical technique of robotic radical prostatectomy and provide practical recommendations based on available reports and personal experience. We also critically review the current experience on RARP worldwide and compare the available data with the gold standard open RRP series. Material and Methods: A systematic review of the literature was performed for all published manuscripts between 1997 and 2008 using the keywords – ‘robotic radical prostatectomy, ‘robot-assisted radical prostatectomy’, ‘laparoscopic radical prostatectomy’ and ‘robotic’ using the Medline database. Results: A total of 226 original manuscripts on RARP were identified. Manuscripts were selected according to their relevance to the current topic (i.e. original articles, number of patients in the series, prospective data collection) and incorporated into this review. Conclusions: Eight years after the first RARP, multiple series are mature enough to demonstrate safety, efficiency and reproducibility of the procedure, as well as oncologic and functional outcomes comparable to its open counterpart. Further prospective, randomized studies comparing both surgical techniques are necessary in order to draw more definitive conclusions.




“A unique instrumental malfunction during robotic prostatectomy.”

Park, S. Y., J. J. Ahn, et al. (2010).

Yonsei Med J 51(1): 148-150.


Over the past decade, the introduction of robotics in the field of medicine has provided a new approach to patients requiring surgery, and both its advantages and disadvantages are currently under study by many groups worldwide. The use of robotics has especially been considered by the urological community as a treatment option in radical prostatectomy. The current case report is one in which the da Vinci Surgical System, with fourth arm use was employed in radical prostatectomy. This case presents a unique occurrence in which a bolt of the Prograsper forcep became loose during an operation, leading to diminished device functionality and later impedance of its removal. A circumstance such as this has not previously been reported, so we introduce for other robotic surgeons our unique instrumental malfunction case during a robotic prostatectomy.




“Radical prostatectomy reigns supreme.”

Rayala, H. J., J. P. Richie, et al. (2009).

ONCOLOGY 23(10).


The clinical incidence of prostate cancer continues to increase in the patient population, while the actual mortality has remained relatively low. As clinicians, we struggle to identify those patients who require intervention for their disease and to determine which treatment modality is best. Active surveillance, brachytherapy, external-beam radiation therapy, and surgical radical prostatectomy (RP) are the current options for prostate cancer treatment, each with a distinct impact on a patients health-related quality of life. We believe that for the majority of patients with organ-confined prostate cancer, RP remains the gold standard with respect to both oncologic success and maximization of quality of life. Herein we discuss the advantages of RP.




“Robot-assisted laparoscopic prostatectomy for a giant prostate with retrieval of vesical stones.”

Singh, I., J. E. Hudson, et al. (2010).

International Urology and Nephrology: 1-5.


Aim: To report and describe the technique of robot assisted prostatectomy (RAP) and retrieval of vesical stones. Methods: We describe the technique of RAP and retrieval of vesical stones under endoscopic guidance. The relevant published English literature (Pub MedTM) was also searched for giant enlargement of prostate glands in order to ascertain their management. Results: An elderly, male with a BMI of 32.49, clinically diagnosed as a case of giant BPH (prior negative prostate biopsy) with vesical stones and severe LUTS, was successfully managed by modified robot assisted laparoscopic technique of prostatectomy with removal of bladder stones. The specimen weighed 384 g. The total ORT, estimated blood loss and hospital stay was 300 min, 600 cc and 3 days, respectively. The final histology was predominant BPH with an incidental focal adenocarcinoma within the distal left prostate. The patient is continent and doing fine at a follow up of 12 months with the serum PSA < 0.006 ng/ml. Discussion: Giant prostatic enlargement is an uncommonly reported entity. Minimally invasive management of massively enlarged prostate with associated bladder stones is a challenging task. Traditionally such patients have been managed with open surgery. The present case of giant prostate enlargement (incidental localized prostate cancer) with vesical stones was successfully managed by a combination of robotic prostatectomy and removal of bladder stones under flexible endoscopic guidance. The technical problems and nuances associated with the technique of robotic assisted prostatectomy (RAP) for giant prostate enlargement have been discussed. To the best of our knowledge the present case is the largest (384 g) reported case of cancer prostate (concomitant vesical stone), to be removed by minimally invasive robot assisted laparoscopic technique in the English literature (PubMedTM). © 2010 Springer Science+Business Media, B.V.




“Effect of posterior urethral reconstruction (PUR) in early recovery of urinary continence after robotic-assisted radical prostatectomy.”

Soo, D. K., H. K. Tae, et al. (2009).

Korean Journal of Urology 50(12): 1203-1207.


Purpose: Prolonged urinary incontinence is one of the greatest concerns for patients undergoing radical prostatectomy. One of the possible causes for this urinary incontinence is a postoperative deficiency of the external striated urethral sphincter (EUS) complex and continence nerves. We evaluated the effect of posterior urethral reconstruction (PUR) in the early recovery of urinary continence after robotic-assisted radical prostatectomy. Materials and Methods: Between January 2008 and March 2009 we performed robotic-assisted radical prostatectomy with PUR in 30 patients (PUR group) and without PUR in 30 patients (non-PUR group). We compared perioperative parameters and postoperative continence rates between the two groups. Continence was defined as no pads or one diaper per 24 hours and was assessed 1 month, 3 months, and 6 months after the procedure. Results: Patients in the PUR group achieved better continence rates at 1 month (43% vs. 35%) and 3 months of follow-up (89% vs. 64%). At 6 months of follow-up, the continence rate was similar between the two groups (96% vs. 90%). No major complications were observed in the PUR group. However, 2 cases of anastomotic site leakage and 1 case of delayed bleeding were observed in the non-PUR group. Conclusions: Posterior urethral reconstruction appears to be an easy and reproducible technique in robotic-assisted radical prostatectomy. Our early experience demonstrates that PUR in robotic-assisted radical prostatectomy appears to confer early continence recovery and reduce intraoperative complications. ©The Korean Urological Association, 2009.




“Robot-assisted radical prostatectomy: advances since 2005.”

Su, L. M. (2009).

Curr Opin Urol.


PURPOSE OF REVIEW: To provide an update of recent studies relevant to robot-assisted radical prostatectomy, highlighting technical modifications and associated functional outcomes, mid-term oncologic results and patient perception and satisfaction. RECENT FINDINGS: Several recent studies have investigated methods of further reducing the morbidities associated with prostatectomy, namely erectile dysfunction and incontinence. These studies provide important anatomic insights into additional mechanisms responsible for potency and incontinence and measures for preserving both. Mid-term oncologic outcomes have also been reported; further substantiating the role of robotics in the treatment of clinically localized prostate cancer. SUMMARY: The technique of robotic prostatectomy has evolved over the last decade with significant efforts in improving functional outcomes following surgery. However, aggressive-marketing campaigns and lack of regulation of hospital websites may be contributing to unrealistic expectations in patients who choose to undergo robotic prostatectomy, resulting in dissatisfaction for some patients. National interests in this topic will likely result in the mandate for more stringent studies to assess the comparative effectiveness of robot-assisted prostatectomy with other competing therapies for clinically localized prostate cancer.




“Transition from pure laparoscopic to robotic-assisted radical prostatectomy: A single surgeon institutional evolution.”

Trabulsi, E. J., J. C. Zola, et al. (2010).

Urologic Oncology: Seminars and Original Investigations 28(1): 81-85.


Purpose: To review a single surgeon experience of transitioning to a robotic-assisted laparoscopic prostatectomy program (RALP) with prior pure laparoscopic radical prostatectomy (LRP) experience. Materials and methods: A retrospective review of surgical results from a single surgeon performing LRP transitioning to RALP was performed. Two hundred five patients undergoing RALP by a single, fellowship-trained, urologic oncologist were analyzed and compared with 45 patients undergoing LRP by the same surgeon. Operative, pathologic, and functional outcomes were evaluated. Validated questionnaires, including the International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF), were utilized for assessing urinary and sexual parameters. Results: Preoperative parameters (age, PSA, Gleason score) were similar in both RALP and LRP groups. Operative time (190 vs. 299 minutes), estimated blood loss (253 vs. 299 ml), and length of stay (1.6 vs. 2.6 days) were reduced in RALP vs. LRP. Although not statistically significant, there was a trend toward fewer transfusions with RALP (2.0% vs. 4.4%) as well as a lower positive margin rate in organ-confined (pT2) disease (9.8%, RALP vs. 20%, LRP). Continence at 12 months was 94% following RALP as opposed to 82% after LRP. In preoperatively potent men undergoing bilateral nerve sparing procedures, RALP conferred 81% potency at 12 months as opposed to only 62% following LRP. Conclusions: The transition from LRP to RALP, in concert with an institutional commitment to a successful robotic surgery program, has yielded superior operative, oncologic, and functional results. © 2010 Elsevier Inc. All rights reserved.




“Sexual dysfunction after radical prostatectomy.”

Wagner, L., A. Faix, et al. (2009).

Dysfonctions sexuelles après prostatectomie totale 19(SUPPL. 4).


Erectile dysfunction is not the only sexual dysfunction that impact quality of life of patients following radical prostatectomy for prostate cancer. Patients must be informed about these consequences and also about the prevention and treatment modalities that could be proposed after surgery. Preoperative erectile function and couple motivation are predictive of the quality of the sexual relationship after radical prostatectomy. A preoperative erectile dysfunction must be investigated as well as if it was the main symptom (evaluation of comorbidities, cardiovascular and psychological risk factors). The quality of the preservation of the neurovascular bundles is the other main determinant that must be decided according to cancer characteristics and performed according to a mastered surgical technic. © 2009 Elsevier Masson SAS. All rights reserved.




“Impact of posterior rhabdosphincter reconstruction during robot-assisted radical prostatectomy: Retrospective analysis of time to continence.”

Woo, J. R., S. Shikanov, et al. (2009).

Journal of Endourology 23(12): 1995-1999.


Background and Purpose: Posterior rhabdosphincter (PR) reconstruction during robot-assisted radical prostatectomy (RARP) was introduced in an attempt to improve postoperative continence. In the present study, we evaluate time to achieve continence in patients who are undergoing RARP with and without PR reconstruction. Methods: A prospective RARP database was searched for most recent cases that were accomplished with PR reconstruction (group 1, n = 69) or with standard technique (group 2, n = 63). We performed the analysis applying two definitions of continence: 0 pads per day or 0-1 security pad per day. Patients were evaluated by telephone interview. Statistical analysis was carried out using the Kaplan-Meier method and log-rank test. Results: With PR reconstruction, continence was improved when defined as 0-1 security pad per day (median time of 90 vs 150 days; P = 0.01). This difference did not achieve statistical significance when continence was defined as 0 pads per day (P = 0.12). Conclusions: A statistically significant improvement in continence rate and time to achieve continence is seen in patients who are undergoing PR reconstruction during RARP, with continence defined as 0-1 security/safety pad per day. A larger, prospective and randomized study is needed to better understand the impact of this technique on postoperative continence. © Mary Ann Liebert, Inc.




“Robotic radical prostatectomy in east Asia: development, surgical results and challenges.”

Yip, S. and H. G. Sim (2010).

Curr Opin Urol 20(1): 80-85.


PURPOSE OF REVIEW: The shift toward robot-assisted laparoscopic radical prostatectomy has reshaped the surgical approach for localized prostate cancer in America and many parts of Europe. Its impact on Asia, however, has been somewhat delayed and less widespread compared with western countries. We reviewed and surveyed the evolving trends in robotic prostatectomy in east Asia and describe how the influence of cancer demography, financial reimbursement models, refinements in robotic technology and robotic surgical training will alter the future direction of the procedure in this region. RECENT FINDINGS: There are about 50 systems installed in east Asia. Numerous centers have reported successful implementation of robotic prostatectomy program, with transfusion rate of 7-26.4%. Margin positivity for T2 disease ranges from 9.8 to 24%, whereas continence rates range from 75 to 94% over 3-6 months. Significant increase in number of prostatectomy has been observed in some centers. SUMMARY: The outlook for robotic prostatectomy in east Asia remains rosy despite the obstacles in financial reimbursement, patient volume and surgical skill development. Future robotic systems with smaller footprint, leaner instrument arms and lower costs will help to accelerate its integration into more Asian hospitals.