“Robotic-assisted partial cystectomy with en bloc excision of the urachus and the umbilicus for urachal adenocarcinoma.”
Correa, J. J., T. S. Hakky, et al. (2009).
Journal of Robotic Surgery: 1-4.
We report two cases of urachal adenocarcinoma managed with robotic-assisted partial cystectomy. A detailed description of the robotic technique including methods used to resect the tumor, urachus, and umbilicus en bloc is described. A review of the management of urachal adenocarcinoma is presented. The robotic approach is technically feasible and safe, and is an attractive alternative to traditional open or laparoscopic-assisted partial cystectomy for this uncommon genitourinary malignancy. © 2009 Springer-Verlag London Ltd.
“Lower urinary tract fistula: The minimally invasive approach.”
Dorairajan, L. N. and A. K. Hemal (2009).
Current Opinion in Urology 19(6): 556-562.
Purpose of review: A variety of fistulas occur involving the lower urinary tract with adjacent organs namely the vagina, uterus, rectum and colon. Most of these arise out of surgical complications and contribute significantly to the morbidity of the procedures. Surgical reconstruction remains the mainstay in the management. This article reviews the use of minimal-access procedures in reconstruction of lower urinary tract fistulas focusing on the bladder. Recent findings: Recently, numerous reports of laparoscopic and robot-assisted surgical repair of these fistulas have shown that these techniques can be used with efficacy and safety with added advantages of short hospital stay, reduced morbidity associated with surgical incision and lower blood loss. Robot-assisted surgery has the advantage of facilitating intracorporeal suturing, making laparoscopic reconstruction easier. However, the steep learning curve and the high cost of robotic surgery are limiting factors. Summary: Prevention of lower urinary tract fistula requires improvement in the quality and technique of surgery and minimizing surgical errors. Minimal access procedures offer surgical treatment with low morbidity but with higher cost. Open surgical repair is being used widely for treating these fistulas at this time, worldwide. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.
“Ureteropelvic junction obstruction: Which is the best treatment today?”
Gallo, F., M. Schenone, et al. (2009).
Journal of Laparoendoscopic and Advanced Surgical Techniques 19(5): 657-662.
The aim of this review is to critically compare the different procedures performed for the treatment of ureteropelvic junction obstruction (UPJO) in order to identify, currently, the best treatment that a urologist should propose to patients with this condition. Three different types of procedures were assessed: open pyeloplasty (OP), endopyelotomy, and laparoscopic pyeloplasty (LP). Regarding efficacy, success rates of 94.1, 62-83, and 95.9-97.2% were reported for OP, endopyelotomy, and LP, respectively. Concerning operative time and length of hospital stay, no extensive data are available in the literature, although endopyelotomy seems to provide shorter times with respect to those reported after OP and LP. Regarding the complication rate, it was very similar after the different techniques and due to the respective approaches. Overall, our data support the conclusion that LP provided a balance between the highly successful technique reported by OP and the quick postoperative recovery provided by the endoscopic approach. Anyway, in spite of these clear advantages, the reproducibility of LP is still strongly limited by the challenge of the learning curve. The da Vinci® robot (Intuitive Surgical, Inc., Sunnyvale, CA), providing an extraordinary vision and precision of surgical movement, appears to be changing this scenario, allowing naïve surgeons to achieve very good results after few procedures. In this setting, robot-assisted pyeloplasty seems to be emerging as the new standard of care in the patients with UPJO, which will further take place over the other techniques once its costs decrease. © 2009, Mary Ann Liebert, Inc.
“Robotic Repair of Primary Symptomatic Obstructive Megaureter with Intracorporeal or Extracorporeal Ureteric Tapering and Ureteroneocystostomy.”
Hemal, A. K., R. Nayyar, et al. (2009).
Abstract Objective: To describe the technique, feasibility, and effectiveness of robotic ureteric tapering (intra- or extracorporeal) and ureteroneocystostomy with and without ureteric stones retrieval in patients with symptomatic primary obstructive megaureter. Materials and Methods: Seven patients (one bilateral) (mean age: 28.3 years) with symptomatic or complicated congenital primary obstructive megaureter were considered for robot-assisted laparoscopic reconstruction. All surgical steps were performed purely robotically via transperitoneal access by single surgeon including ureteric reimplantation and retrieval of ureteral stones, except in two patients where ureteral tapering was done extracorporeally. The relevant perioperative details, complications, and functional outcomes were analyzed. Besides clinical follow-up, objective evaluation was done with diuretic renogram and intravenous urography. Results: Total mean operative time and surgeon’s console time were 142.5 and 127.5 minutes (range: 115-230 and 100-210), respectively, with an estimated blood loss of less than 50 mL. Mean analgesic requirement was 175 mg of diclofenac sodium and oral feeds were started after 12 hours (range: 7-16). Average hospital stay was 3.2 days (range: 2-6). Complications included one case of perioperative urinary tract infection. Average follow-up period was 16 months (range: 11-20). Follow-up ultrasonography and intravenous urography confirmed reduction of hydronephrosis and good drainage. The mean split renal function of the salvaged kidney was 41.2% at last follow-up when compared with preop average value of 41.3%. Conclusions: Robotic repair and removal of ureteric stones in primary symptomatic obstructive megaureter is safe, feasible, and effective with either intracorporeal or extracorporeal ureteric tapering. It has minimal perioperative morbidity and durable success as demonstrated with subjective and objective evaluation.
“Robotic-assisted laparoscopic extravesical ureteroneocystostomy for management of adult ureteral duplication with upper pole prostatic urethral insertion.”
Larson, J. A., J. J. Tomaszewski, et al. (2009).
Journal of the Society of Laparoendoscopic Surgeons 13(3): 458-461.
A 55-year-old male presented with progressive lower urinary tract symptoms and renal colic. The workup revealed a complete left ureteral duplication with a hydronephrotic upper pole moiety inserting into the prostatic urethra. Using a 5-port transperitoneal robotic-assisted laparoscopic technique, an extravesical upper pole ureteroneocystostomy was performed. Clinical follow-up and repeat imaging documented symptomatic and radiographic improvement. Robotic-assisted laparoscopic reconstructive techniques are feasible and efficacious in the management of adult ureteral anomalies. © 2009 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the Society of Laparoendoscopic Surgeons, Inc.
“Robot-assisted Ureteroureterostomy in the Adult: Initial Clinical Series.”
Lee, D. I., C. W. Schwab, et al. (2009).
OBJECTIVES: To report what we believe is the first series of robot-assisted ureteroureterostomy (RAUU) in adults with greater than 24-month follow-up because ureteral stricture disease can be difficult to manage. METHODS: During 2004-2006, a total of 3 patients were found to have complex ureteral pathology: 2 with refractory symptomatic ureteral strictures and 1 with a complete ureteral transection. After thorough discussion of all available treatment options, these patients agreed to undergo RAUU. RESULTS: All patients had successful primary reanastomosis of the ureter robotically. Average operating room time was 136.6 minutes. Mean hospital stay was 3 days. All patients had ureteral stents placed during the operation. All patients at last follow-up were noted to be pain free with stable T((1/2)) on nuclear renal scan. CONCLUSIONS: RAUU is a potential treatment option for ureteral strictures in carefully selected patients. These cases may include failed endopyelotomy, refractory ureteral stricture, or cases of ureteral transection in which a ureteral reimplantation may be difficult. The robotic platform provides excellent reconstructive capabilities that may be difficult to obtain for surgeons who are not performing laparoscopic cases in high volume.
“The role and extent of pelvic lymphadenectomy in the management of patients with invasive urothelial carcinoma.”
Lerner, S. P. (2009).
Current Treatment Options in Oncology 10(3-4): 267-274.
Lymph node metastases are the most important prognostic variable in determining outcome following radical cystectomy. An anatomic bilateral node dissection includes at a minimum the external and internal iliac and obturator lymph nodes. An extended node dissection may include the distal aortic and vena caval nodes, bilateral common iliac, and pre-sacral nodes, which receive direct lymphatic drainage from the posterior bladder and trigone. This approach sets up the cystectomy, maximizes sensitivity for detection of nodal metastasis, assures optimum local pelvic cancer control, and accurately identifies those high-risk patients with node metastases who may benefit from adjuvant chemotherapy. Lymph node retrieval is affected by several variables of node specimens addition to the anatomic extent of the node dissection. These include presentation to the pathologist in packets, specimen processing and what the pathologist calls a lymph node, and patient age. The current TNM staging system accounts for the number and size of node metastases and may be improved by incorporating lymph node density, which is a composite variable incorporating the number of positive nodes and number of nodes retrieved – a possible surrogate for the extent of the node dissection. Innovations in imaging including novel MRI contrast agents and lymphoscintigraphy may improve the pre-treatment and intra-operative identification of node metastases and lymphatic anatomy. Minimally invasive surgical techniques including robotic-assisted laparoscopic cystectomy may improve peri-operative outcomes but must meet the standard of anatomic node dissection and long-term cancer control afforded by the gold standard of anatomic radical cystectomy and bilateral pelvic and iliac node dissection. © Springer Science+Business Media, LLC 2009.
“Robotic radical cystoprostatectomy: oncological and functional analysis.”
Palou Redorta, J., J. M. Gaya Sopena, et al. (2009).
Cistoprostatectomía radical robótica: análisis oncológico y funcional. 33(7): 759-766.
INTRODUCTION: The da Vinci robotic laparoscopic surgery, has been shown in radical prostatectomy, optimal functional and oncological results with a lower learning curve, greater comfort and vision for the surgeon, and proper preservation of the neurovascular bundles. This has led to begin the experience with robotic radical cystectomy (RRC). OBJECTIVES: Review our initial experience in CRR, evaluating surgical and functional results obtained, and also immediate and short-term complications. MATERIAL AND METHODS: Between December 2007 and January 2009 we performed nine robotic radical cystoprostatectomy and in seven patients robotic lymphadenectomy (LDN). Five patients had a muscle-invasive disease and 4 non-muscle invasive bladder cancer. The median age was 57 years (range 34-81). Urinary diversion was performed extracorporeally in all cases, 3 cases an ileal conduit and 6 an Studer neobladder in 3 of these 6 cases, the urethra-neobladder anastomosis was performed intracorporeally. RESULTS: The average time of surgery was 300 minutes (range 280-420) in the ileal conduit and 360 (range 330-540) in the Studer. No cases required conversion or blood transfusion. The median number of nodes removed by LDN robotics was 10 (range 6-18). The pathology revealed 3 pT0. 2 CIS, 3 pT3, 1 pT4b (positive margins). With a median follow up of 7 months there have been no peritoneal implant and only one ureteral stenosis. Oral diet was initiated in 5 cases at 48 hours. Of the 6 patients with preserved sexual function preoperatively and followup of more than 3 months, 2 had full erection at 1 month, 2 at 3 and 6 months, and the remaining 2 presented with a full erection with 5 PD inhibitors at 3 and 9 months. All patients with neobladder presented correct daytime continence. The average hospital stay was 8.5 days (range 7-19). CONCLUSIONS: The radical robotic cystectomy with extracorporeal reconstruction of the urinary diversion offers good early functional and surgical outcomes. The careful preservation of the neurovascular bundles in radical pelvic surgery provides excellent results in urinary and sexual function.
“Ureteric reconstruction and replacement.”
Peeker, R. (2009).
Current Opinion in Urology 19(6): 563-570.
Purpose of review: To review the recent advances on ureteric reconstruction and replacement, in particular, ileal ureteric replacement and laparoscopic and robotic-assisted ureteral reconstruction. Recent findings: Recently, the ureteric replacement with bowel has been carefully assessed by several authors, and the results are quite impressive. Also, very recent studies on laparoscopic and robotic-assisted ureteral repair have been published. Outcomes appear very promising, allowing for a faster recovery and shorter hospital stay for the patient. Summary: Today, we can conclude that the field of ureteric reconstruction and replacement is still evolving. Old techniques are supported by an increasing degree of evidence, and new, more minimally invasive surgical strategies emerge. Clearly, there are some disadvantages as well as difficulties to overcome with the new techniques; however, recent studies appear to present promising results. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.
“Treatment of Bladder Diverticula, Impaired Detrusor Contractility, and Low Bladder Compliance.” Powell, C. R. and K. J. Kreder (2009).
Urol Clin North Am 36(4): 511-525.
Bladder diverticula are common enough to be encountered by most urologists in practice but are reported less frequently in the literature than they were 50 years ago. Some patients can be managed nonoperatively, whereas others will need surgical intervention consisting of bladder outlet reduction and possibly removal of the diverticulum itself. In addition to the decision to operate, the timing of each intervention deserves careful consideration. Cystoscopy, computed tomography with contrast, urodynamic studies, cytology, and voiding cystourethrography play important roles in informing the clinician. Many new techniques for treatment of the bladder outlet and the diverticulum are available, such as laparoscopy and robotic surgery.
“”Robotic cystectomy and the internet: separating fact from fiction” by Pruthi R.S. et al.”
Spiess, P. E. (2009).
Urol Oncol 27(6): 686.
“What is the best treatment for ureteropelvic junction obstruction? in response to: Ureteropelvic junction obstruction: Which is the best treatment today?”
Thiel, D. D. (2009).
Journal of Laparoendoscopic and Advanced Surgical Techniques 19(5): 669.
“Impact of previous abdominal surgery on robot-assisted radical cystectomy.”
Yuh, B. E., J. Ciccone, et al. (2009).
Journal of the Society of Laparoendoscopic Surgeons 13(3): 398-405.
Objective: We analyzed the effect of previous abdominal surgery (PAS) on consecutive patients who underwent robot-assisted radical cystectomy (RARC). Materials and Methods: From 2005 to 2008, 73 patients at a single institution underwent RARC with bilateral extended pelvic lymph node dissection and urinary diversion. Lysis of adhesions was performed robotically and laparoscopically. Records were reviewed to assess the impact of PAS on operative outcomes and complications up to 3 months after surgery. Results: Of the 73 patients, 37 (51%) had undergone PAS. Of these 37, 6 (16%) had PAS above the umbilicus, and 31 (84%) had surgery either above and below or strictly below the umbilicus. Patients with PAS were significantly older than those without (P<0.01). No statistically significant difference was seen with respect to blood loss transfusion requirement, operative time, lysis of adhesion time, length of ICU stay, overall hospital stay, or the need for reoperation between patients with PAS and those without PAS. The overall postoperative complication rate was higher in the group with PAS (P=0.04). Lymph node yield was higher in patients without PAS (P<0.01). Patients with PAS below the umbilicus had a significantly longer hospital stay than patients with surgery strictly above the umbilicus had (P=0.01). Whether individuals had previously undergone single or multiple surgeries had no significance. Conclusion: Robot-assisted radical cystectomy in patients with a history of previous surgery may carry a higher risk for postoperative complications. However, previous operations do not appear to affect the likelihood of a safely completed robotic operation. Patients should be counseled about their risk of obstacles after surgery. © 2009 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the Society of Laparoendoscopic Surgeons, Inc.
“A Critical Analysis of the Actual Role of Minimally Invasive Surgery and Active Surveillance for Kidney Cancer.”
Heuer, R., I. S. Gill, et al. (2009).
Context: The incidence of renal cell carcinomas (RCCs) has increased steadily-most rapidly for small renal masses (SRMs). Paralleling the changing face of RCC in the past 2 decades, new, less invasive surgical options have been developed. Laparoscopic radical nephrectomy (LRN) is an established procedure for the treatment of RCC. Treatment of SRMs includes open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), thermal ablation, and active surveillance. Objective: To present an overview of minimally invasive treatment options and data on surveillance for kidney cancer. Evidence acquisition: Literature and meeting abstracts were searched using the terms renal cell carcinoma, minimally invasive surgery, laparoscopic surgery, thermal ablation, surveillance, and robotic surgery. The articles with the highest level of evidence were identified with the consensus of all the collaborative authors and reviewed. Evidence synthesis: Renal insufficiency, as measured by the glomerular filtration rate, occurs more often after radical nephrectomy than partial nephrectomy (PN). OPN and LPN show comparable results in long-term oncologic outcomes. The treatment modality for SRMs should therefore be nephron-sparing surgery (NSS). In select patients, thermal ablation or active surveillance of SRMs is an alternative. Conclusions: LRN has become the standard of care for most organ-confined tumours not amenable to NSS. Amongst NSS options, PN is the treatment of choice, yet remains underutilised in the community. Initial data during its learning curve revealed that LPN had higher urologic morbidity. However, current emerging data indicate that in experienced hands, LPN has shorter ischaemia times, a lower complication rate, and equivalent long-term oncologic and renal functional outcomes, yet with decreased patient morbidity compared to OPN. Robotic partial nephrectomy is being explored at select centres, and cryotherapy and radiofrequency ablation are options for carefully selected tumours. Active surveillance is an option for selected high-risk patients. Percutaneous needle biopsy is likely to gain increasing relevance in the management of small renal tumours. © 2009 European Association of Urology.
“Current status of nephron-sparing robotic partial nephrectomy.”
Hsieh, T. C., T. W. Jarrett, et al. (2009).
Curr Opin Urol.
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.
“Minimally invasive nephron sparing management for renal tumors in solitary kidneys.”
Turna, B., J. H. Kaouk, et al. (2009).
J Urol 182(5): 2150-2157.
PURPOSE: We present a large series of minimally invasive nephron sparing surgery outcomes in solitary kidneys with a focus on treatment selection criteria, and oncological and functional outcomes. MATERIALS AND METHODS: Of 1,019 patients who underwent minimally invasive nephron sparing surgery since September 1997 at our institution 36, 36 and 29 underwent laparoscopic partial nephrectomy, cryoablation and radio frequency ablation, respectively, for tumors in a solitary kidney. Data, including patient and tumor characteristics, surgery details, complications, and postoperative renal function and intermediate term oncological outcomes in each patient, were obtained by telephone contact or from charts. The 3 groups were compared for perioperative, functional and oncological outcomes. RESULTS: On multivariate analysis tumor size, aspect and remnant kidney status were independent predictors of treatment selection. Cancer specific and overall survival at 2 years was 100% and 91.2% for laparoscopic partial nephrectomy, 88.5% and 88.5% for cryoablation, and 83.9% and 83.9% for radio frequency ablation, respectively. Disease-free survival was significantly better for laparoscopic partial nephrectomy than for cryoablation and radio frequency ablation (100% vs 69.6% and 33.2%, respectively, p <0.0001). The mean estimated glomerular filtration rate change for laparoscopic partial nephrectomy, cryoablation and radio frequency ablation of 17, 3 and 7 ml per minute per 1.73 m(2) reflected a 26%, 6% and 13% decrease from baseline, respectively, which was statistically significant (p = 0.0016). CONCLUSIONS: Laparoscopic partial nephrectomy and probe ablative procedures can be safely and efficiently done for renal tumor in patients with a solitary kidney. Intermediate term oncological outcomes are superior for laparoscopic partial nephrectomy despite somewhat poorer renal function outcomes than those of cryoablation and radio frequency ablation.
“Robotic partial nephrectomy without renal hilar occlusion.”
White, W. M., R. K. Goel, et al. (2009).
OBJECTIVE To evaluate operative outcomes among patients undergoing robotic partial nephrectomy (RPN) without renal hilar clamping. PATIENTS AND METHODS This was a prospective observational study of patients undergoing RPN under perfused conditions (pRPN). Patients with solitary, radiographically enhancing renal cortical lesions gave consent for pRPN. Salient demographic data, including age, body mass index (BMI) and preoperative tumour size were obtained. Operative data, including mean operative time, estimated blood loss (EBL), and the presence of any complications, were collected. Renal function was evaluated before and after RPN. Remote adverse events were noted. The pRPN group was then retrospectively compared to a contemporary group of patients who had RPN with renal hilar occlusion. Endpoints for comparison included operative time, warm ischaemia time, EBL, length of hospitalization, and the rate of adverse events. RESULTS Between February 2008 and December 2008, eight had underwent pRPN; the mean age was 59.3 years, mean BMI 28.7 kg/m(2), mean operative time 167 min, mean EBL 569 mL and mean hospitalization 3.75 days. Pathology showed renal cell carcinoma in five patients and oncocytoma in three; the mean tumour size was 2.4 cm. Final pathological margins were negative in all patients. Adverse events included one transfusion and one deep venous thrombosis. When compared to the contemporary group who had RPN with hilar clamping, the operative time was shorter (P = 0.035) and EBL greater (P = 0.018) in the pRPN group. There was no significant difference between the groups in transfusion rate, and no significant difference in renal function before and after surgery either group. CONCLUSIONS For selected small renal cortical masses, RPN is safe without renal hilar occlusion. The EBL was higher during pRPN but with no significant difference in the rate of transfusion.
“14-Gauge angiocatheter: The assist port.”
Hotaling, J. M., S. Shear, et al. (2009).
Journal of Laparoendoscopic and Advanced Surgical Techniques 19(5): 699-701.
Introduction: Minimally invasive techniques have emerged as the standard of care for some procedures in pediatric urology. In an effort to minimize required ports for robotic-assisted laparoscopic (RAL) surgeries in children, we describe in this article a novel technique for using a 14-gauge (G) angiocatheter as an assist port in concert with various readily available cystoscopic equipment. Materials and Methods: After the insertion of robotic ports and docking, the da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, CA), using a 14-G angiocatheter, was placed through the abdominal wall under direct vision. The 14-G angiocatheter was then used to facilitate stent placement, provide a port for semiflexible cystoscopic graspers, and to evacuate cautery smoke. At the end of each case, the 14-G angiocatheter was removed under direct vision prior to undocking the robot. Results: A 14-G angiocatheter was used as an assist port in 17 RAL urologic procedures (16 RAL dismembered pyeloplasties and 1 robotic orchiopexy). No complications occurred and the angiocatheter’s use avoided the placement of 3- or 5-mm additional assist ports. Conclusions: The 14-G angiocath technique uses existing equipment, requires no closure, and can be placed anywhere on the abdominal wall. It allows the RAL dismembered pyeloplasty to be performed with only two instrument ports and no additional trocar for assistance. This is the first described method in the urologic literature of using a 14-G angiocatheter to maximize operative assistance while minimizing port placement in pediatric RAL surgery. © 2009, Mary Ann Liebert, Inc.
“Health Information Quality on the Internet in Urological Oncology: A Multilingual Longitudinal Evaluation.”
Lawrentschuk, N., R. Abouassaly, et al. (2009).
Urology 74(5): 1058-1063.
Objectives: To compare the quality of uro-oncological Web sites, to assess for language or disease differences across Western languages, and to perform a longitudinal comparison between 2004 and 2009. Uro-oncological Internet information quality is considered variable but no comprehensive analysis exists. Methods: Health on the Net (HON) principles may be applied to Web sites using an automated toolbar function. Using the Google search engine (http://www.Google.com), in 2004 and 2009, 2400 Web sites were assessed using the keywords prostate, bladder, kidney, and testicular cancer in English, French, German, and Spanish. The first 150 Web sites in each language had HON principles measured-a comparison between 2004 and 2009 was done. A further analysis of site sponsorship was undertaken. Results: Regardless of language or cancer type, most sites are not HON accredited. English has consistently more than English, French, Spanish, or German. For the respective languages in 2009, prostate has the most (29, 14%, 16%, 12%), followed by bladder (29%, 22%, 14%, 13%), kidney (25%, 15%, 10%, 13%), and testis (26%, 19%, 7.11%). Significant differences were found comparing language and organ groups. The quality improved from 2004 to 2009. Nonprofit organizations (51%), government and/or educational (39%), commercial (20%), with urologists last (14%) were accredited. Conclusions: A lack of validation of most uro-oncological sites should be appreciated by urologists. Additionally, there is a discrepancy in quality and number of Web sites across uro-oncological diseases and major Western European languages, but with some improvement seen recently. We need to encourage informative, ethical, and reliable complimentary health Web sites on the Internet and direct patients to them. © 2009 Elsevier Inc. All rights reserved.
“Editorial Comment on: Laparoscopy in German Urology: Changing Acceptance among Urologists.”
Menon, M. (2009).
European Urology 56(6): 1080-1081.
“Robotic surgery in male infertility and chronic orchialgia.”
Parekattil, S. J. and M. S. Cohen (2009).
Curr Opin Urol.
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.
“Has the Advent of Minimally Invasive Surgery Altered the Risk Profile of Patients Undergoing Prostatectomy?”
Barlow, L. J., M. J. Mann, et al. (2009).
OBJECTIVES: To determine whether the decreased short-term morbidity associated with minimally invasive surgery (MIS) has resulted in an alteration in the disease-specific risk profile of prostatectomy patients. MIS in many fields has resulted in an expansion in the pool of patients willing to undergo surgery. METHODS: The Columbia Urologic Oncology Database was queried, and 1751 patients undergoing radical prostatectomy between 2000 and 2007 were identified. The cohort was divided into 2 groups: patients who received surgery before or after the initiation of robotic-assisted laparoscopic radical prostatectomy (RALRP) at our institution (from 2003 onward). Age at surgery, Kattan Nomogram (KN) score, prostate-specific antigen (PSA), Gleason score sum, and tumor stage were compared using unpaired t tests with Welch correction and Mann-Whitney tests. RESULTS: A total of 663 patients underwent prostatectomy from 2000 to 2002 (“pre-MIS era”), and 1088 patients had surgery in 2003 or later (“MIS era”), of which 519 and 569 underwent RALRP and open prostatectomy, respectively. There was no significant difference between the 2 eras regarding age, Kattan Nomogram score, or tumor stage. However, there was a significant difference in preoperative PSA (P = .01) and Gleason sum (P = .0002). In a comparison of the pre-MIS era with RALRP patients, only PSA differed significantly (P = .0002). CONCLUSIONS: The advent of MIS for prostate cancer did not significantly alter the characteristics of patients undergoing prostatectomy at our institution. Although advancements in surgical techniques may improve clinical outcomes, this study does not suggest a consequential effect on the risk stratification of patients choosing surgery for prostate cancer.
“Cost Comparison of Robotic, Laparoscopic, and Open Radical Prostatectomy for Prostate Cancer.”
Bolenz, C., A. Gupta, et al. (2009).
BACKGROUND: Demand and utilization of minimally invasive approaches to radical prostatectomy have increased in recent years, but comparative studies on cost are lacking. OBJECTIVE: To compare costs associated with robotic-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and open retropubic radical prostatectomy (RRP). DESIGN, SETTING, AND PARTICIPANTS: The study included 643 consecutive patients who underwent radical prostatectomy (262 RALP, 220 LRP, and 161 RRP) between September 2003 and April 2008. MEASUREMENTS: Direct and component costs were compared. Costs were adjusted for changes over the time of the study. RESULTS AND LIMITATIONS: Disease characteristics (body mass index, preoperative prostate-specific antigen, prostate size, and Gleason sum score 8-10) were similar in the three groups. Nerve sparing was performed in 85% of RALP procedures, 96% of LRP procedures, and 90% of RRP procedures (p<0.001). Lymphadenectomy was more commonly performed in RRP (100%) compared to LRP (22%) and RALP (11%) (p<0.001). Mean length of hospital stay was higher for RRP than for LRP and RALP. The median direct cost was higher for RALP compared to LRP or RRP (RALP: $6752 [interquartile range (IQR): $6283-7369]; LRP: $5687 [IQR: $4941-5905]; RRP: $4437 [IQR: $3989-5141]; p<0.001). The main difference was in surgical supply cost (RALP: $2015; LRP: $725; RRP: $185) and operating room (OR) cost (RALP: $2798; LRP: $2453; RRP: $1611; p<0.001). When considering purchase and maintenance costs for the robot, the financial burden would increase by $2698 per patient, given an average of 126 cases per year. CONCLUSIONS: RALP is associated with higher cost, predominantly due to increased surgical supply and OR costs. These costs may have a significant impact on overall cost of prostate cancer care.
“Double-Pigtail Stenting of the Ureters: Technique for Securing the Ureteral Orifices During Robot-Assisted Radical Prostatectomy for Large Median Lobes.”
Douaihy, Y. E., G. Y. Tan, et al. (2009).
Abstract Patients with large median prostate lobes undergoing robot-assisted radical prostatectomy are at potential risk of ureteric orifice injury, during posterior bladder neck transection and vesicourethral anastomosis reconstruction. We describe our technique of in situ robot-assisted ureteral stenting with double-pigtail stents for accurate observation and preservation of the ureteral orifices. We have performed this maneuver in over 30 patients in our cohort of over 1500 patients undergoing robot-assisted radical prostatectomy to date-none of these patients developed urinary leak or bladder neck contracture, and had uneventful cystoscopic removal of stents at 6 weeks after surgery.
“Robotic Assisted Laparoscopic Salvage Prostatectomy for Radiation Resistant Prostate Cancer.”
Eandi, J. A., B. A. Link, et al. (2009).
Journal of Urology.
Purpose: We report on outcomes of robotic assisted laparoscopic radical prostatectomy as salvage local therapy for radiation resistant prostate cancer. Materials and Methods: We retrospectively reviewed the charts of all patients who underwent robotic assisted laparoscopic radical prostatectomy for biopsy proven prostate cancer after primary radiation treatment. Patient characteristics, intraoperative and perioperative data, and oncological and functional outcomes were assessed. Results: A total of 18 patients were identified with a median followup of 18 months (range 4.5 to 40). Primary treatment was brachytherapy in 8 patients and external beam radiation in 8, while 2 underwent proton beam therapy. Median age at salvage robotic assisted laparoscopic radical prostatectomy was 67 years (range 53 to 76). Median preoperative prostate specific antigen was 6.8 ng/ml (range 1 to 28.9) and median time to surgery after primary treatment with radiation was 79 months (range 7 to 146). Median operative parameters for estimated blood loss, surgery length and hospital stay were 150 ml, 2.6 hours and 2 days, respectively. No patient required conversion to open surgery or a blood transfusion, or experienced a rectal injury. Perioperative complications occurred in 7 patients (39%) of which the most common was urine leak identified by postoperative cystogram. Five patients (28%) had a positive surgical margin. Although some patients had limited followup, 6 (33%) were continent and 67% were free of biochemical progression. Conclusions: Robotic assisted laparoscopic radical prostatectomy can be performed safely as salvage local therapy after failed radiation therapy. Outcomes are comparable to those of large series of open salvage prostatectomy. © 2010 American Urological Association.
“Editorial Comment on: Cost Comparison of Robotic, Laparoscopic and Open Radical Prostatectomy for Prostate Cancer.”
Graefen, M. (2009).
“Detection of Subclinical CO2 Embolism by Transesophageal Echocardiography During Laparoscopic Radical Prostatectomy.”
Hong, J. Y., W. O. Kim, et al. (2009).
Objectives: To document incidences of subclinical embolism in laparoscopic radical prostatectomy with continuous monitoring using transesophageal echocardiography (TEE). Methods: A total of 43 patients scheduled for elective robotic-assisted laparoscopic radical prostatectomy under general anesthesia were enrolled in this study. A 4-chamber view of 5.0-MHz multiplane TEE was continuously monitored to detect any intracardiac bubbles as an embolism. An independent TEE specialist reviewed the tapes for interpretation, and emboli were classified as 1 of 5 stages. Cardiorespiratory instability during gas emboli entry was defined as an appearance of cardiac arrhythmias, sudden decrease in mean arterial blood pressure >20 mm Hg, or an episode of pulse oximetric saturation <90%. Results: Gas embolisms were observed in 7 of 41 (17.1%) patients during transection of the deep dorsal venous complex. Of them, 1, 3, 1, and 2 showed stage I, II, III, and IV, respectively. However, there were no signs of cardiorespiratory instability associated with emboli. The 95% confidence interval for gas embolism was 0.204%-0.138%. No correlation was observed between episodes of gas embolism and blood gas variables or end-tidal CO2 partial pressure. Conclusions: Subclinical gas embolisms occur in 17.1% of laparoscopic radical prostatectomies. We should consider that this procedure has a potential for serious gas embolism, especially with the increasing popularity of laparoscopic prostatectomy using robot-assisted techniques. © 2009 Elsevier Inc. All rights reserved.
“Comparative effectiveness of minimally invasive vs open radical prostatectomy.”
Hu, J. C., X. Gu, et al. (2009).
JAMA – Journal of the American Medical Association 302(14): 1557-1564.
Context: Minimally invasive radical prostatectomy (MIRP) has diffused rapidly despite limited data on outcomes and greater costs compared with open retropubic radical prostatectomy (RRP). Objective: To determine the comparative effectiveness of MIRP vs RRP. Design, Setting, and Patients: Population-based observational cohort study using US Surveillance, Epidemiology, and End Results Medicare linked data from 2003 through 2007. We identified men with prostate cancer who underwent MIRP (n=1938) vs RRP (n=6899). Main Outcome Measures: We compared postoperative 30-day complications, anastomotic stricture 31 to 365 days postoperatively, long-term incontinence and erectile dysfunction more than 18 months postoperatively, and postoperative use of additional cancer therapies, a surrogate for cancer control. Results: Among men undergoing prostatectomy, use of MIRP increased from 9.2% (95% confidence interval [CI], 8.1%-10.5%) in 2003 to 43.2% (95% CI, 39.6%-46.9%) in 2006-2007. Men undergoing MIRP vs RRP were more likely to be recorded as Asian (6.1% vs 3.2%), less likely to be recorded as black (6.2% vs 7.8%) or Hispanic (5.6% vs 7.9%), and more likely to live in areas with at least 90% high school graduation rates (50.2% vs 41.0%) and with median incomes of at least $60 000 (35.8% vs 21.5%) (all P<.001). In propensity score-adjusted analyses, MIRP vs RRP was associated with shorter length of stay (median, 2.0 vs 3.0 days; P<.001) and lower rates of blood transfusions (2.7% vs 20.8%; P<.001), postoperative respiratory complications (4.3% vs 6.6%; P=.004), miscellaneous surgical complications (4.3% vs 5.6%; P=.03), and anastomotic stricture (5.8% vs 14.0%; P<.001). However, MIRP vs RRP was associated with an increased risk of genitourinary complications (4.7% vs 2.1%; P=.001) and diagnoses of incontinence (15.9 vs 12.2 per 100 person-years; P=.02) and erectile dysfunction (26.8 vs 19.2 per 100 person-years; P=.009). Rates of use of additional cancer therapies did not differ by surgical procedure (8.2 vs 6.9 per 100 person-years; P=.35). Conclusion: Men undergoing MIRP vs RRP experienced shorter length of stay, fewer respiratory and miscellaneous surgical complications and strictures, and similar postoperative use of additional cancer therapies but experienced more genitourinary complications, incontinence, and erectile dysfunction. ©2009 American Medical Association. All rights reserved.
“Prostate cancer treatments in Belgium.”
Idrissi Kaitouni, M. and T. Roumeguère (2009).
Le point sur les traitements du cancer de prostate en Belgique 30(4): 270-278.
The authors present a flyover of current management of prostate cancer. The topics include active surveillance, surgery, radiotherapy, high-intensity focalized ultrasound (HIFU). Current hormone treatment modalities as well as chemotherapy for hormone-resistant prostate cancer (HRPC) management are also reported. Reasonable evidence has supported the safety and feasibility, during a period of 5-10 years, of an active surveillance regimen for men with low-risk prostate cancer. Radical prostatectomy is an effective form of therapy for patients with clinically significant prostate cancer. Outcomes are highly sensitive to variations in surgical technique. The risks of perioperative complications such as urinary and sexual dysfunction appear to be as great with robotic-assisted prostatectomy as with any other technique. External beam radiotherapy (EBRT) is an effective noninvasive form of curative therapy with a long-term risk of troublesome bowel and sexual and urinary dysfunction. EBRT can also be used in adjuvant manner or in combination. Brachytherapy, is a convenient effective form of radiotherapy targeted for selected patients with clinically confined cancer without evidence of extraprostatic extension on imaging. Excellent outcomes require meticulous technique. Acute urinary symptoms are frequent ; and the long-term risks of proctitis and erectile dysfunction seem comparable to the risks associated with external beam radiotherapy. HIFU has been used widely in Europe for complete ablation of the prostate, especially in the elderly who are unwilling or unable to undergo more invasive radical therapy. For low-or intermediate-risk cancer, the short- and intermediate-term oncologic results have been acceptable but need confirmation in prospective multicenter trials presently underway. HIFU is associated with a risk of acute urinary symptoms requiring transurethral resection before or after HIFU. Erectile function has not been adequately documented after HIFU. HIFU holds promise for focal ablation of prostate cancer and in case of recurrence after EBRT. Androgen-deprivation therapy is not recommended for men with localized prostate cancer. For locally extensive cancer, androgen-deprivation therapy should be used alone only for the relief of local symptoms in men with a life expectancy of < 5 years who are not eligible for more aggressive treatment. Management of HRPC is actually accepted with docetaxel chemotherapy based regimens.
Kaouk, J. H. (2009).
Urology 74(5): 1012.
“Re: JSLS. 2008;12(1):9-12 A da vinci robot system can make sense for a mature laparoscopic prostatectomy program.”
Lotan, Y. (2009).
Journal of the Society of Laparoendoscopic Surgeons 13(3): 465.
“Application of Continuous Tension to Aid in Performing the Vesicourethral Anastomosis for Robot-Assisted Prostatectomy.”
Meeks, J. J., L. C. Zhao, et al. (2009).
Abstract Objectives: Approximation of the bladder to urethra during robot-assisted laparoscopic prostatectomy (RALP) is a critical step toward achieving long-term continence. To determine the impact on surgical outcomes after RALP, we compare two techniques for constructing the vesicourethral anastomosis. Methods: One hundred fifty-four men underwent RALP by one surgeon between 2005 and 2007. The vesicourethral anastomosis was performed in a standard Van Velthoven fashion for the first 61 patients. The anastomosis in the remaining 93 patients was performed in a running fashion with the sutures under continuous tension applied by the surgical assistant and the third robotic arm. Operative times and surgical outcomes were recorded prospectively. Results: When comparing standard Van Velthoven to continuous tension anastomosis, we demonstrate equivalent oncologic outcomes, continence and time required for the anastomosis. Yet, the frequency of complications related to the anastomotic technique, such as urine leaks, bladder neck contractures and migrated hemo-lock clips, were significantly lower with the continuous tension technique compared to the standard Van Velthoven running anastomosis. Conclusions: Performing the vesicourethral anastomosis under continuous tension demonstrated improved outcomes compared to the Van Velthoven anastomosis by allowing persistent close apposition of the bladder to urethra. Additionally, the learning curve associated with implementation of a new anastomotic technique was negligible.
“Preoperative Criteria to Select Patients for Bilateral Nerve-sparing Robotic-assisted Radical Prostatectomy.”
Novara, G., V. Ficarra, et al. (2009).
J Sex Med.
ABSTRACT Introduction. To date, no study has analyzed the predictors of potency recovery in a robot-assisted laparoscopic radical prostatectomy (RALP) series. A novel risk stratification for erectile function recovery after retropubic radical prostatectomy (RRP) has been proposed recently by Briganti et al. from the University Vita-Salute San Raffaele in Milan, Italy. Aim. To evaluate the potency rate in a series of consecutive patients who underwent bilateral nerve-sparing RALP, to identify the preoperative predictors of erectile function recovery, and to validate the risk-group stratification of Briganti et al. Methods. The clinical records of all patients who underwent RALP for clinically localized prostate cancer between April 2005 and April 2009 were prospectively collected in the Prostate Cancer Padua Database. For the present study, we extracted all consecutive cases receiving a bilateral nerve-sparing technique with a minimum follow-up >/=12 months. Main Outcome Measures. Twelve-month potency rate after RALP, defined as an International Index of Erectile Function 6 (IIEF-6) score >/=18. Results. Data showed that 129 out of 208 enrolled patients (62%) were potent 12 months after surgery. Age (hazard ratio [HR]: 2.8; P < 0.001), Charlson score (HR: 2.9; P = 0.007), and baseline IIEF-6 score (HR: 0.8; P < 0.001) were independent predictors of potency recovery at multivariate analysis. According to Briganti et al.’s risk-group stratification, the 12-month potency rate following RALP was 81.9% in the low-risk group, 56.7% in the intermediate-risk group, and 28.6% in the high-risk group (P < 0.001). Conclusions. In the era of robotic surgery, the key point for the success of the nerve-sparing technique remains the accurate selection of patients. Age </=65 years, absence of associated comorbidities, and good preoperative erectile function are the most important preoperative factors to select those patients for whom bilateral nerve-sparing RALP can achieve the best results. Novara G, Ficarra V, D’Elia C, Secco S, De Gobbi A, Cavalleri S, and Artibani W. Preoperative criteria to select patients for bilateral nerve-sparing robotic-assisted radical prostatectomy. J Sex Med **;**:**-**.
“The Impact of Previous Inguinal or Abdominal Surgery on Outcomes After Robotic Radical Prostatectomy.”
Siddiqui, S. A., L. S. Krane, et al. (2009).
OBJECTIVES: To evaluate our experience with robotic radical prostatectomy (RRP) in the setting of previous inguinal or abdominal surgery. METHODS: From a prospective cohort of 3950 consecutive patients who underwent transperitoneal RRP between September 2001 and September 2008, we identified 1049 (27%) patients with a history of abdominal or inguinal surgery. Demographic data including body mass index, age at the time of surgery, serum prostate-specific antigen, and clinical stage were prospectively recorded. Clinical endpoints measured included estimated blood loss (EBL), console time, total operative time, and perioperative complications. Degree of adhesiolysis at the time of surgery was graded into minor, moderate, or large. RESULTS: In comparing patients with previous abdominal or inguinal surgery with no surgery, there were no differences in EBL (150 vs 151 mL, P = .79), total operative time (158 minutes v second 155 minutes, P = .15), body mass index (27.8 vs 27.4, P = .2), preoperative prostate-specific antigen (6.1 vs 6.3, P = .07) and clinical stage (P = .71). A total of 243 (24%) of patients with previous surgery required adhesiolysis vs 246 (8%) of patients with no previous surgery (P <.001). Appendectomy was the most common previous surgery identified (11%). Patients with a previous history of colectomy had the highest incidence of adhesiolysis (72%). A total of 5 bowel injuries were recorded in the cohort of 3950 patients; of these 3 patients had a history of prior abdominal surgery. CONCLUSIONS: Previous abdominal or inguinal surgery is not a contraindication to RRP. The majority of these patients can have their procedure safely performed without an increased risk of complications.
“Commentary on Salvage robotic-assisted radical prostatectomy: Initial results and early report of outcomes. Boris RS, Bhandari A, Krane LS, Eun D, Kaul S, Peabody JO, Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI.”
Smith, J. (2009).
Urologic Oncology: Seminars and Original Investigations 27(6): 693-694.
To evaluate the initial results of salvage robotic-assisted radical prostatectomy (SRARP) after recurrence following primary radiotherapy (RT) for localized prostate cancer. Between December 2002 and January 2008, 11 patients had SRARP with pelvic lymph node dissection by 1 surgeon from 1 institution. Six patients had brachytherapy, 3 had external beam RT (EBRT), 1 intensity-modulated RT, and 1 received brachytherapy with an EBRT boost. All patients had prostate cancer on biopsy after RT, with negative computed tomography and bone scan. The mean (range) follow-up was 20.5 (1-77) months. The mean interval from RT to SRARP was 53.2 months; the mean preoperative prostate-specific antigen (PSA) level was 5.2 ng/ml, the operative duration 183 minutes, and the estimated blood loss 113 ml. One patient had prolonged lymphatic drainage, 1 had an anastomotic leak, and 1 had an anastomotic stricture requiring direct vision internal urethrotomy at 3 months. The mean duration of catheterization was 10.4 days and the hospital stay 1.4 days. Three patients had a biochemical recurrence, at 1, 2, and 43 months. In 1 of 2 patients with node-positive carcinoma of the prostate the PSA level failed to reach a nadir of 0 after surgery. In patients with a minimum follow-up of 2 months, 8 of 10 are continent (defined as 0 to 1 pad per day) and 2 have erections adequate for intercourse with the use of phosphodiesterase-5 inhibitors. SRARP after RT-resistant disease recurrence is feasible with minimal perioperative morbidity. Early functional outcomes appear to be at least equivalent with historical salvage RP series. Robotic extended pelvic lymph node dissection is safe and can improve the accuracy of surgical staging. A longer follow-up is necessary to better assess the functional and oncologic outcomes. © 2009 Elsevier Inc. All rights reserved.
“Myocardial infarction and subsequent death in a patient undergoing robotic prostatectomy.”
Thompson, J. (2009).
AANA Journal 77(5): 365-371.
A 52-year-old patient, ASA physical status IV, undergoing a radical prostatectomy for cancer with a robotic system had a cardiac arrest 3 hours into the case. All attempts to resuscitate were unsuccessful, and several hours later he was pronounced dead. Underlying patient comorbidity and procedural issues contributed to the patient’s death. The patient had a history of coronary artery disease that required the placement of drug-eluting stents 2 years before this surgical procedure. The preoperative cardiac evaluation and pharmacological management of patients with drug-eluting coronary stents are reviewed. There are a number of positional and technical considerations for patients undergoing robotic surgical procedures, especially in relation to the requirement of low-lithotomy and steep Trendelenburg positions. The cardiac and respiratory systems are especially vulnerable to the extreme and lengthy head-down position. The needed positioning, combined with the problems associated with insufflation, presents a unique challenge in anesthetic management. This course reviews the current literature on the surgical implications for patients with drug-eluting stents and the physiologic factors related to position and pneumoperitoneum and their associated stressors. By using a review of the contemporary literature, a best-evidence approach to anesthetic management is reviewed.
“Nerve injury-related erectile dysfunction following nerve-sparing radical prostatectomy: A novel experimental dissection model: Original Article.”
Yamashita, S., R. Kato, et al. (2009).
International Journal of Urology 16(11): 905-911.
Objectives: To establish a new experimental rat model in order to define the mechanisms of erectile dysfunction (ED) and to evaluate the changes of neuronal nitric oxide synthase (nNOS) in the pelvic ganglia following nerve-sparing radical prostatectomy. Methods: Sprague-Dawley rats were randomized to sham operation, bilateral cavernous nerve dissection (BCND) and bilateral cavernous nerve resection (BCNR) groups. In the BCND group, the cavernous nerves were only dissected bilaterally from the major pelvic ganglion (MPG) to the apex of the prostate without crushing or cutting. At 1, 2, 4 and 8 weeks after surgery, we examined intracavernous pressure along with arterial pressure (ICP/AP), retrograde dye tracing using Fluorogold (FG) and expression of nNOS in the MPG. Results: Intracavernous pressure and arterial pressure in the BCND group was significantly decreased at 2 and 4 weeks after surgery compared with the sham group, and improved at 8 weeks. The number of FG-positive cells in the MPG also recovered at 8 weeks. ICP/AP and FG-positive cells in the BCNR group were greatly decreased until 8 weeks. The percentage of nNOS-positive cells per total cells was not different between the sham and BCND groups during the experimental period, whereas that in the BCNR group gradually decreased with time. Conclusions: We established a novel rat model, in which cavernous nerve dissection alone caused nerve injury-related ED. We believe that this cavernous nerve dissection model might help clarify the mechanism of nerve injury-related ED and the recovery from ED after nerve-sparing radical prostatectomy. © 2009 The Japanese Urological Association.
“Robotic radical prostatectomy in east Asia: development, surgical results and challenges.”
Yip, S. K. and H. G. Sim (2009).
Curr Opin Urol.
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.