Abstrakt Urologie Prosinec 2009

“Lymph node dissection for bladder cancer: the issue of extent and feasibility in the minimally invasive era.”

Ghavamian, R. and A. A. Hakimi (2009).

Expert Rev Anticancer Ther 9(12): 1783-1792.


Lymph node dissection in bladder cancer is an integral part of radical cystectomy. It allows for accurate staging of the patient and will, therefore, serve to dictate additional treatment and add prognostic information. The issue of what is an adequate lymphadenectomy as to the extent and boundaries of the operation, specifically the cephalad extent, has been the focus of recent debate. Some have suggested that lymph node yield, in terms of number, could serve as a surrogate for the adequacy of the node dissection and, thus, the oncologic efficacy of the operation. It has also been suggested that it is a marker for the experience of the operating surgeon. What is meant by a limited, standard and extended lymph node dissection varies among different publications. Recent evidence suggests that an ‘extended’ node dissection infers oncologic efficacy. With the advent of minimally invasive and, specifically, robotic-assisted surgery, more cystectomies are approached robotically. As such, there has been recent debate as to whether a robotic-assisted procedure can emulate the open approach, satisfying the accepted boundaries and extent of dissection and ultimately leading to equivalent oncologic outcomes without increasing morbidity. In this review, we focus on the extent of lymphadenectomy in bladder cancer by reviewing the lymphatic drainage and arguments in favor of a more extended dissection. We will then address the minimally invasive techniques, focusing on robotic-assisted surgery, and review the evidence suggesting that this is a promising new technique that results in acceptable nodal yield and potentially equivalent oncologic outcomes with no added morbidity.




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

Ng, C. K., E. C. Kauffman, et al. (2010).

European Urology 57(2): 274-282.


Background: Robotic cystectomy is an emerging alternative for treatment of invasive bladder cancer (BCa). However, reduction in postoperative morbidity relative to the open approach has not been demonstrated. Objective: To compare complication rates in patients undergoing robotic versus open radical cystectomy (RC). Design, setting, and participants: A prospective cohort study of 187 consecutive patients undergoing RC at our institution-104 open RC, 83 robotic RC. Intervention: Open or robotic RC with urinary diversion. Measurements: Demographic, perioperative, and complication data were recorded prospectively. Thirty-day and 90-d complication rates were assessed using the modified Clavien complication scale. Data were evaluated using χ2 and multivariate logistic regression analyses. Results and limitations: At 30 d, the open group demonstrated a higher overall complication rate (59% vs 41%; p = 0.04) as well as more major complications (30% vs 10%; p = 0.007). At 90 d, the overall complication rate was greater in the open group, but this was not statistically significant (62% vs 48%; p = 0.07). However, there was a significantly higher major complication rate in the open cohort (31% vs 17%; p = 0.03). When subjected to logistic regression analysis, robotic cystectomy was an independent predictor of fewer overall and major complications at 30 and 90 d. High American Society of Anesthesiologists (ASA) score (3-4) and longer surgical time were independent predictors of major complications. Though this is one of the largest published RC series, the sample size is relatively small. Moreover, despite the two patient cohorts being similarly matched, the study was not performed in a randomized fashion. Conclusions: Patients undergoing robotic cystectomy experienced fewer postoperative complications than those undergoing open cystectomy. Robotic cystectomy is an independent predictor of fewer overall and major complications. Until long-term oncologic results are available, robotic cystectomy should still be considered investigational. © 2009 European Association of Urology.




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

Park, S. Y., W. Jeong, et al. (2009).

BJU International 104(11): 1718-1721.


Objective To report a new technique of robot-assisted laparoscopic nephroureterectomy (RANU) using a hybrid port, as RANU has recently become a minimally invasive treatment option for upper tract transitional cell carcinoma (TCC). Patients and methods Eleven consecutive patients underwent RANU by one surgeon. The first six patients were repositioned after the nephrectomy, from flank to lithotomy position, and the robot was re-docked for excision of the distal ureter and bladder cuff. The last five patients were treated by a new RANU technique that did not require a change of position or movement of the patient cart. We analysed data obtained before, during and after RANU. Results The total operative duration was reduced by ≈50 min in last five patients. There was no improvement in hospital stay or estimated blood loss. There were no transfusions and positive surgical margins in any patient. Maintaining the patient in a flank position allows gravity to displace the bowel away from the distal ureter, not only shortening the surgery but also improving exposure of the distal ureterectomy and closure of the bladder cuff. Conclusions The new RANU technique is a safe and feasible treatment option for upper tract TCC. © 2009 BJU INTERNATIONAL.




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

Pruthi, R. S., M. E. Nielsen, et al. (2009).

Journal of Urology.


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 patients 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.




“Partial ureteropelvic junction obstruction managed by robotic excision and ureteropyelostomy.”

Richards, K. A., I. Singh, et al. (2009).

Can J Urol 16(6): 4932-4935.




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

Smith, A., R. Kurpad, et al. (2009).

Journal of Urology.


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.




“Robot-assisted laparoscopic ureteroureterostomy for proximal ureteral obstructions in children.”

Smith, K. M., D. Shrivastava, et al. (2009).

Journal of Pediatric Urology 5(6): 475-479.


Objective: Ureteropelvic junction obstruction is a common presentation in the pediatric population, but proximal ureteral obstructions are rare. In this setting, robot-assisted laparoscopy (RAL) offers a minimally invasive option to open or traditional laparoscopic repair. The present study demonstrates successful RAL in two children with proximal ureteral obstructions: one with a right retrocaval ureter and one with a left ureter entrapped between two lower-pole crossing vessels. Method: After retrograde placement of a double-J ureteral stent, the child was secured in a lateral decubitus position exposing the affected side. A three-port RAL system was used to dissect free the obstructed ureter. A spatulated watertight ureteroureterostomy was then fashioned after transposition of the ureter into an anatomic position. Sutures and free instruments were passed into the peritoneal cavity via the 5-mm instrument ports, thus obviating the need for a separate assistant port. Results: RAL provided for crisp visualization, meticulous dissection, and precise approximation of the reconstructed ureter. In both patients, blood loss was negligible, narcotic use was minimal, and length of stay was roughly 30 h. Follow-up imaging at 1 month showed excellent hydronephrosis resolution for both reconstructions. Conclusion: These two cases demonstrate the feasibility of RAL for proximal ureteral anomalies in the pediatric population. © 2009 Journal of Pediatric Urology Company.




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

Thiel, D. D., T. J. Leroy, et al. (2009).



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.




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

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

BJU International 104(11): 1722-1729.


BACKGROUND Pelvi-ureteric junction (PUJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by intrinsic or extrinsic obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital in origin; however, acquired conditions at the level of the ureteropelvic junction may also present with symptoms and signs of obstruction. Historically, open pyeloplasty and endoscopic techniques have been the main surgical options with the intent of complete excision or incision of the obstruction. The advent of laparoscopy and robotic-assisted applications has allowed for minimally invasive reconstructive surgery that mirrors open surgical techniques. AIMS We review the current status of robotic-assisted laparoscopic pyeloplasty and report on the result, continuing evolution, and potential role for this surgical procedure. MATERIALS AND METHODS A review of the recent literature encompassing laparoscopic and robotic-assisted pyeloplasty was conducted with particular attention to operative techniques, surgical outcomes, and complication rates. Results Laparoscopic and robotic-assisted approaches are able to duplicate the open technique, and not surprisingly, are now being shown to be as efficacious as the gold standard open approach. The laparoscopic remains technically challenging due to the high proficiency level required for intracorporeal suturing, although added experience has resulted in shorter operative times. The advent of robotics has further expanded the breadth of this reconstructive procedure while preserving the benefits of decreased pain, shorter hospitalization, rapid convalescence, and an improved cosmetic result. DISCUSSION The introduction of robotics to the field of minimally invasive surgery facilitates this procedure and may allow for more widespread implementation by surgeons of varying skill levels. These benefits must be balanced against the increased costs of the robotic platform. CONCLUSION Clinical reports have demonstrated that robotic-assisted pyeloplasty is a safe, feasible, and effective technique for treating ureteropelvic junction obstruction in short term studies. Additional studies with prolonged follow-up will ultimately provide valuable information as to the long-term efficacy of robotic-assisted laparoscopic pyeloplasty. © 2009 BJU INTERNATIONAL.




“Robotic Cystectomy: Its Time Has Come.”

Vira, M. A. and L. Richstone (2009).

J Urol.




“Laparoscopic versus robotic pyeloplasty: man versus machine.”

Atalla, M. A., Z. Dovey, et al. (2010).

Expert Rev Med Devices 7(1): 27-34.


With all its different presentations and etiologies, ureteropelvic junction obstruction has been a topic for much research and debate. For several decades, the ‘gold standard’ of treatment was unequivocally an Anderson-Hynes dismembered pyeloplasty. Various surgical modifications and minimally invasive alternatives have been studied. It was not until the last two decades that laparoscopic and robotic approaches have threatened to supplant the classic open approach as the preferred surgical treatment option. While the debate between the laparoscopic and robotic approaches has been a heavily contested one, it has rarely been founded on prospective, well-matched evidence. We review the existing literature and present our perspective on the clinical, academic and economic aspects of this contest between man and machine.




“Prospective analysis of completely stentless robot-assisted pyeloplasty in children.”

Casale, P. and S. Lambert (2009).

Journal of Robotic Surgery: 1-3.


Robot-assisted pyeloplasty (RAP) is emerging as an effective tool for treatment of ureteropelvic junction obstruction (UPJO) in the pediatric population. Typically stents are utilized for RAP and removed four weeks after the procedure. We present our prospective experience with stentless RAP. Twenty children between the ages of 12 and 113 months (mean age 56 months) underwent transperitoneal RAP for UPJO utilizing the DaVinci surgical system. Outcome measures included operative time, length of hospital stay, and resolution of obstruction by ultrasonography, magnetic resonance urography (MRU), and/or diuretic radionuclide imaging (DRI). All patients successfully underwent robot-assisted laparoscopic pyeloplasty without conversion to pure laparoscopy or open procedure. Mean operative time was 124.7 min with a mean console time of 82.3 min. The mean hospital stay was 18 h. Of the 20 patients, 13/20 (65%) had resolution or improvement in the degree of hydronephrosis. The other patients had no evidence of obstruction based upon follow-up MRU or DRI. Stentless RAP is a safe and effective option for surgical treatment of UPJO. A larger prospective long-term cohort is needed to confirm the safety and efficacy of the stentless approach. © 2009 Springer-Verlag London Ltd.




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

Dols, L. F., N. F. Kok, et al. (2009).

Transpl Int.


Summary 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.




“Parental Satisfaction After Open Versus Robot Assisted Laparoscopic Pyeloplasty: Results From Modified Glasgow Children’s Benefit Inventory Survey.”

Freilich, D. A., F. J. Penna, et al. (2009).

Journal of Urology.


Purpose: Since its inception, robot assisted laparoscopic pyeloplasty has rapidly become the minimally invasive surgical intervention of choice for treating ureteropelvic junction obstruction at our institution. The large initial investment in robot assisted surgery is frequently justified by its association with improved optics and instrument articulation, decreased postoperative pain, shorter length of hospitalization and improved cosmesis. However, there are no data specifically showing patient satisfaction with robot assisted laparoscopic pyeloplasty compared to traditional open surgery. Materials and Methods: A previously validated satisfaction survey (Glasgow Children’s Benefit Inventory) with 14 additional questions specifically addressing postoperative satisfaction was mailed to all parents (as patient proxy) of children who had undergone open or robot assisted laparoscopic pyeloplasty between January 2006 and December 2008. Results: A total of 78 parents responded (response rate 70%). All responses achieving statistical significance favored robot assisted laparoscopic pyeloplasty. Parents of children who underwent robot assisted laparoscopic pyeloplasty reported significantly higher satisfaction with “overall life,” confidence, self-esteem, burden of postoperative followup and size of incision scar. Conclusions: Parent satisfaction was greater with robot assisted laparoscopic pyeloplasty than with open surgery regarding amount of cosmesis and recovery. Interestingly the differences in satisfaction were not as large as anticipated, suggesting the impact of confounding factors such as age and preoperative parental expectations. Future large-scale prospective studies using validated surveys specific to pediatric surgery are needed to elucidate further the true benefits of minimally invasive surgical technology such as robot assistance. © 2009 American Urological Association.




“Robotic-assisted laparoscopic pyeloplasty: initial Australasian experience.”

Hall, R. M., D. G. Murphy, et al. (2009).

Journal of Robotic Surgery: 1-5.


Laparoscopic dismembered pyeloplasty has a success rate in excess of 90% for the treatment of uretero-pelvic junction (UPJ) obstruction. Laparoscopic intracorporeal suturing, however, remains technically challenging and may lead to prolonged operating times. Robotic-assisted suturing using the da Vinci® surgical system (Intuitive Surgical, CA, USA) may reduce the difficulty associated with intra-corporeal suturing. The da Vinci® surgical system was used to facilitate intra-corporeal suturing in adults undergoing trans-peritoneal robotic-assisted laparoscopic pyeloplasty (RALPY) at our institution. Initially, the robot was only docked for the anastomosis, but in the later part of the series the robot was used for all parts of the dissection and reconstruction. Peri-operative and outcome data were recorded prospectively. Twenty-four patients underwent RALPY over a 4-year period. The mean age was 46.6 (range 18-76) years. The mean total operative time was 211 min (range 150-317 min) with an anastomotic time of 44 min (range 30-55 min). The mean estimated blood loss was 56 ml (10-150 ml) and there was one temporary urine leak managed by 24 h of urethral catheterization. The median length of stay was 4 (2-10) days. Patients underwent diuretic renography at 6 months post surgery, and satisfactory renal drainage was demonstrated in all cases. RALPY is a feasible and safe option for the management of UPJ obstruction. This technology may reduce the difficulty associated with complex laparoscopic suturing and facilitate shorter operative times with excellent outcomes. This is now our preferred approach for all patients opting for surgical management of UPJ obstruction. © 2009 Springer-Verlag London Ltd.




“A Critical Analysis of the Actual Role of Minimally Invasive Surgery and Active Surveillance for Kidney Cancer.”

Heuer, R., I. S. Gill, et al. (2010).

European Urology 57(2): 223-232.


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.




“Robot-Assisted Laparoscopic Nephrectomy and Contralateral Ureteral Reimplantation in Children.”

Lee, R. S., A. S. Sethi, et al. (2009).

J Endourol.


Abstract 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 laparoscopic donor nephrectomy for kidney transplantation. An evaluation of 35 procedures.”

Louis, G., J. Hubert, et al. (2009).

 Transplantation rénale à partir de donneurs vivants prélevés sous laparoscopie assistée par robot. À propos d’une série de 35 cas 5(7): 623-630.


Introduction: Renal transplantation with living donor is actually the best technique for renal replacement therapy, particularly with the problem of shortage of organs. Laparoscopic nephrectomy is actually developed because of low surgical mortality and morbidity. Our medical centre uses an original removal method: robot-assisted laparoscopic donor nephrectomy. Methods: We report our 35 first robot-assisted kidney removals at our centre. Results: After a precise preoperative evaluation, all donors choosed robotic-assisted laparoscopic surgery. The mean hospitalitalization duration was 5,5 days. The serum creatinine level reached respectively 107, 104, 91, 71 μmol/l within a period of 1, 2, 3 and 4 years after the operation. None of the recipients required post-transplant dialysis. No vascular complication was listed. The urological complications observed were: six lymphoceles, one ureteral stenosis and one ureteral necrosis. Ten patients (29% of the recipients) showed 16 biopsy-proven episodes of acute rejection. All donors and recipients were alive after a mean graft survival of 3,8 ± 1 years. Thirty-four grafts fared well with an average serum creatinine level respectively of 107, 124, 125 μmol/l at 1, 2, 3 and 4 years after transplantation. Conclusion: Considering the very low morbidity rate and the positive long term results for donors as well as for recipients, robot-assisted donor laparoscopy seems to be a safe and efficient surgical technique. By offering optimal operative conditions to the urological surgeon, it would serve as a favourable alternative to the present kidney graft shortage. © 2009 Association Société de néphrologie.




“Surgery: Emergence of robot-assisted partial nephrectomy.”

Matin, S. F. (2009).

Nature Reviews Urology 6(11): 579-580.




“Robotic Partial Nephrectomy for Renal Tumors Larger Than 4 cm.”

Patel, M. N., L. S. Krane, et al. (2010).

European Urology 57(2): 310-316.


Background: Minimally invasive partial nephrectomy (PN) is most commonly performed for renal tumors ≤4 cm in size. Robotic PN (RPN) for tumors >4 cm has not been assessed. Objective: To evaluate the safety and feasibility of RPN for tumors >4 cm in the context of patients undergoing RPN for tumors ≤4 cm. Design, setting, and participants: We reviewed data for 71 consecutive patients who underwent transperitoneal RPN at a tertiary care center between August 2007 and September 2009 by a single surgeon. Patients were stratified into two groups: 15 with tumors >4 cm on preoperative imaging (group 1) and 56 patients with tumors ≤4 cm (group 2). Intervention: All patients underwent transperitoneal RPN by a single surgeon. Measurements: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed and compared between groups. We used χ2 and student t tests for categorical and continuous variables, respectively. A p value <0.05 was considered statistically significant. Results and limitations: Mean radiographic tumor size was 5.0 cm (4.1-7.9) for group 1 and 2.1 cm (0.7-3.8) for group 2. No significant differences were found between groups for estimated blood loss, total operative time, hospital stay, complication rates, and change in estimated glomerular filtration rate. Patients with larger tumors had longer median warm ischemia times (25 vs 20 min; p = 0.011). Limitations of our study include the retrospective nature the analysis, small sample size, and single-surgeon experience. Conclusions: In our initial experience, RPN for tumors >4 cm is safe and feasible, showing comparable outcomes to RPN for smaller tumors, although with longer warm ischemia times. Future studies with extended follow-up are necessary to determine the viability of RPN for large tumors as an effective form of treatment. © 2009 European Association of Urology.




“Feasibility of right and left transvaginal retroperitoneal nephrectomy: From the porcine to the cadaver model.”

Perretta, S., P. Allemann, et al. (2009).

Journal of Endourology 23(11): 1887-1892.


Purpose: Minimally invasive nephrectomy performed through a natural orifice such as the vagina could enhance cosmesis and improve patient acceptance of the procedure and postoperative recovery. As the vagina has already been proposed as a site of specimen extraction in patients undergoing laparoscopic nephrectomy, the aim of this study was to explore the feasibility of transvaginal, retroperitoneal natural orifice transluminal endoscopic surgery (NOTES) nephrectomy for both left- and right-sided kidneys initially in a porcine model and thereafter in a human cadaver model. Materials and Methods: Ten female pigs underwent NOTES nephrectomy (five having a left nephrectomy and five having right nephrectomy). To do this, each pig was anesthetized and placed in a supine position. A retroperitoneal conduit was established by means of a posterior colpotomy and the retroperitoneal space then entered with a conventional double-channel endoscope (StorzTM). Thereafter, careful blunt dissection allowed a passage to be created up to the renal vessels and proximal ureter which were then dissected and divided separately after endoscopic clipping. We then attempted to reproduce the technique in two formaldehyde-preserved female cadavers. Results: All the porcine procedures were accomplished by a totally NOTES approach with a mean operative time of 50 minutes (range 45-60). No bleeding or injury to any of the retroperitoneal structures occurred. In the two cadavers, the retroperitoneal access was reproduced, but a complete dissection of the kidney was not possible because of the rigor of the surrounding tissues. Conclusions: Transvaginal retroperitoneal NOTES right and left nephrectomy is certainly accomplishable in the porcine model, and the feasibility of the access was confirmed in two cadavers. As a retroperitoneal transvaginal dissection preserves the peritoneum and obviates bowel handling, this work should encourage further development of NOTES accesses for renal surgery. © 2009 Mary Ann Liebert, Inc.




“Experience with laparoscopic pyeloplasty, including robot-assisted laparoscopic surgery, for ureteropelvic junction obstruction.”

Seong, C. K., T. Kang, et al. (2009).

Korean Journal of Urology 50(10): 996-1002.


Purpose: Laparoscopic pyeloplasty was developed as a minimally invasive alternative to an open procedure for the treatment of ureteropelvic junction (UPJ) obstruction. We present our experience with the first 30 consecutive cases of laparoscopic pyeloplasty performed at our institution. Materials and Methods: We studied 30 patients with ureteropelvic junction obstructions who underwent laparoscopic pyeloplasty between March 2004 and March 2009. Of the 30 patients, 5 patients underwent robotassisted laparoscopic pyeloplasty (RALP) since April 2008. Patients were divided into 4 groups according to operative procedure: group 1, early laparoscopic pyeloplasty-dismembered (E/LP-D, n=9); group 2, late laparoscopic pyeloplasty-dismembered (L/LP-D, n=9); group 3, laparoscopic pyeloplasty-Fenger’s method (LP-F, n=7); and group 4, RALP (n=5). Results: The mean age of the patients was 34.0±12.8 years (range, 17-61 years). A crossing vessel was present in 37.9% of cases. Mean follow-up was 30±14 months (range, 11-62 months). Mean operative time was 267.3±78.7 minutes (range, 154-460 minutes), and the average length of the postoperative hospital stay was 4.6±1.6 days (range, 3-10 days). There were no intraoperative complications or transfusion. The success rate was 73.3%. The success rates of E/LP-D, L/LP-D, LP-F, and RALP were 6/9 (66.7%), 7/9 (77.8%), 5/7 (71.4%), and 4/5 (80%), respectively, without significant difference (p > 0.05). Operation time and length of hospital stay were shorter in the L/LP-D group than in the E/LP-D group. Conclusions: Laparoscopic pyeloplasty may be an alternative treatment for an ureteropelvic junction obstruction, but the technical complexity of the procedure has made it difficult for many surgeons to adopt. RALP is a technically feasible management option for UPJ obstruction. ©The Korean Urological Association, 2009.




“Robotic renal surgery: The future or a passing curiosity?”

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

Journal of the Canadian Urological Association 3(3): 231-240.


The development, advancement and clinical integration of robotic technology in surgery continue at a staggering pace. In no other discipline has this rapid evolution occurred to a greater degree than in urology. Although radical prostatectomy has grown to become the prototypical application for the robot, the role of the robot in renal surgery remains controversial. Herein we review the literature on robotic renal surgery. A comprehensive PubMed literature search was performed to identify all published reports relating to robotic renal surgery. All clinically related articles involving human participants were critically appraised in this review. Fifty-one clinical articles were included, encompassing robot-assisted pyeloplasty, nephrectomy, nephroureterectomy, living-donor nephrectomy and partial nephrectomy. Feasibility has been shown for each of these procedures. Robot-assisted techniques have been described for almost all renal-related procedures. However, the intersect between feasibility and necessity as it pertains to robotic renal surgery has yet to be defined. Also, the high cost of surgical robotic technology mandates critical appraisal before adoption, especially in a publicly funded health care system, such as the one present in Canada. © 2009 Canadian Urological Association.




“Initial Clinical Experience with Surgical Technique of Robot-assisted Transperitoneal Laparoscopic Partial Nephrectomy.”

Yang, C. K., K. Y. Chiu, et al. (2009).

J Chin Med Assoc 72(12): 634-637.


Background: The incidental finding of small renal masses has increased due to widespread use of computed tomography as a diagnostic procedure. Some patients with either exophytic renal masses less than 4 cm and suboptimal renal function, a solitary kidney and bilateral renal tumors, or genetic predisposition to renal tumors are considered candidates for laparoscopic partial nephrectomy (LPN). A technical difficulty of LPN is performing laparoscopic intracorporeal suturing under the pressure of warm ischemia time. Because robotic systems have been shown to provide easier intracorporeal suturing, we hypothesized that robotic-assisted LPN might improve efficacy. Methods: Eight patients with a mean age of 41 years and mean tumor size of 2.3 cm underwent robot-assisted LPN between September 2006 and December 2008. Tumor excision and intracorporeal suturing under warm ischemia by renal artery clamp were performed entirely using a robotic system. All perioperative data and pathologic results were reviewed retrospectively. Results: The mean operation time was 160 minutes, and the mean estimated blood loss was 165 mL. The mean warm ischemia time was 33 minutes, and mean postoperative hospital stay was 4.3 days. Average preoperative hemoglobin was 13.0 mg/dL and postoperative hemoglobin was 11.8 mg/dL. Average preoperative creatinine was 1.1 ng/mL and postoperative creatinine was 1.28 ng/mL. There was 1 conversion to laparoscopic nephrectomy due to a positive margin on a frozen section after discussion with family about better oncologic control. The resected lesions included renal cell carcinoma in 5 patients, angiomyolipoma in 2, and a renin-secreting renal tumor in 1 patient. Conclusion: Robot-assisted LPN is feasible and may be a viable alternative to open or LPN in selected patients with small exophytic renal tumors. Compared with standard LPN, the robotic assisted LPN approach with precise renal reconstruction under a safe warm ischemia time is feasible and can be easily adopted by those with experience in robot-assisted surgery.




“Robotic hypospadias surgery: a new evolution.”

Casale, P. and T. S. Lendvay (2009).

Journal of Robotic Surgery: 1-6.


The dictum that “there is nothing new in surgery not previously described,” is quoted regularly and is particularly true of hypospadias. There is an ongoing search for solutions to many troublesome issues concerning surgical treatment of hypospadias, such as what age is the most appropriate to apply surgery, or in how many stages surgery should be performed. We present a case report of the first robotic hypospadias surgery to propose a departure from the standard practice, in the hope of expanding medical expertise and teaching globally. The use of a robot for reconstructive surgery is not novel; its use for extracorporeal surgery is, but we contend that there is no difference in the surgical steps to carry out a hypospadias repair. In addition, we envision that the benefits of applying robotic surgery for extracorporeal reconstructive procedures will greatly impact the current paradigm of surgery and surgical education. For those surgeons who already possess comfort with robotic skills, reconstructive procedures outside of a major cavity are feasible, and time will provide safety and efficacy data. Our hope is that others will join in the advancement of telesurgery and its applications and appreciate the potential expansion of surgical knowledge that will be afforded by this change in how we teach and operate. © 2009 Springer-Verlag London Ltd.



“Evolution of open radical retropubic prostatectomy-how have open surgeons responded to the challenge of minimally invasive surgery?”

Acharya, S. S., K. C. Zorn, et al. (2009).

Journal of Endourology 23(11): 1893-1897.


Introduction: With the advent of minimally invasive surgery (MIS) for treating urologic malignancies, emphasis has been placed on reducing patient morbidity and resuming normal activity. We sought to clarify whether open surgeons (OS) have modified their techniques, surgical equipment, and perioperative management in response to this trend. Methods: A survey sent to all members of the Society of Urologic Oncology assessed changes that OS performing radical retropubic prostatectomy have made in analgesia, operative technique, perioperative management, and follow-up patterns. We also assessed OS sense of competition from MIS. Surgeon perception of the influence MIS had on these changes was scored from 0 to 4 (0=not at all, 1=slightly, 2=moderately, 3=greatly, 4=completely). Overall and major influence by MIS included scores 1-4 and 3-4, respectively. Results: Reduced radical retropubic prostatectomy (RRP) case volume because of MIS competition was reported by 20 OS (24%), with 27 OS (32%) starting to perform MIS, and 20 (24%) doing mostly/exclusively MIS. MIS has influenced OS to reduce incision length (overall influence 56%/major influence 33%), operative time (40%/12%), blood loss (31%/17%), and transfusion rate (33%/14%). MIS has influenced OS to use new instruments (48%/44%) or loupes (20%/9%), modify dissection (45%/31%) or anastomotic technique (14%/12%), and increase the use of hemostatic agents (48%/19%). MIS has reduced convalescence in OS patients by reducing length of stay (52%/28%), time to a regular diet (40%/18%), duration of drain (21%/16%) and Foley (32%/15%), time to return to work (49%/25%), and exercise (44%/21%). MIS has changed follow-up of OS patients by increasing the use of clinical pathways (14%/9%) and validated questionnaires (22%/13%). Conclusions: To date, the influence of MIS on the OS has not been comprehensively assessed. This survey finds that OS report that MIS serves as major competition to the open technique and that it has influenced them to modify their surgical technique, reduce convalescence, and alter follow-up recommendations. © 2009 Mary Ann Liebert, Inc.




“Simplifying Patient Positioning and Port Placement During Robotic-Assisted Laparoscopic Prostatectomy{black small square}.”

Cestari, A., N. M. Buffi, et al. (2009).

European Urology.


Proper patient positioning and port placement is of critical importance in robotic-assisted laparoscopic radical prostatectomy (RALP). Not having the patient in the correct Trendelenburg position or not being able to move the surgical instruments freely in the abdominal cavity can be frustrating, especially for naïve robotic surgeons (ie, those at the beginning of the learning curve for this procedure), and can lead to further difficulties in performing the intervention. We describe the use of a nautical inclinometer and a plastic, double-equilateral triangle with an 8-cm-long border to reach the correct Trendelenburg position easily and to place trocars correctly during RALP. © 2009 European Association of Urology.




“Robot-assisted laparoscopic prostatectomy is not associated with early postoperative radiation therapy.”

Chino, J., F. R. Schroeck, et al. (2009).

BJU International 104(10): 1496-1500.


OBJECTIVE To compare open radical prostatectomy (RP) and robot-assisted laparoscopic prostatectomy (RALP), and to determine whether RALP is associated with a higher risk of features that determine recommendations for postoperative radiation therapy (RT). PATIENTS AND METHODS Patients undergoing RP from 2003 to 2007 were stratified into two groups: open RP and RALP. Preoperative (PSA level, T stage and Gleason score), pathological factors (T stage, Gleason score, extracapsular extension [ECE] and the status of surgical margins and seminal vesicle invasion [SVI]) and early treatment with RT or referral for RT within 6 months were compared between the groups. Multivariate analysis was used to control for selection bias in the RALP group. RESULTS In all, 904 patients were identified; 368 underwent RALP and 536 underwent open RP (retropubic or perineal). Patients undergoing open RP had a higher pathological stage with ECE present in 24.8% vs 19.3% in RALP (P = 0.05) and SVI in 10.3% vs 3.8% (P < 0.001). In the RALP vs open RP group, there were positive surgical margins in 31.5% vs 31.9% (P = 0.9) and there were postoperative PSA levels of 3 0.2 ng-mL in 5.7% vs 6.3% (P = 0.7), respectively. On multivariate analysis to control for selection bias, RALP was not associated with indication for RT (odds ratio (OR) 1.10, P = 0.55), or referral for RT (OR 1.04, P = 0.86). CONCLUSION RALP was not associated with an increase in either indication or referral for early postoperative RT. © 2009 BJU International.




“Adequacy of lymphadenectomy among men undergoing robot-assisted laparoscopic radical prostatectomy.”

Cooperberg, M. R., C. J. Kane, et al. (2010).

BJU International 105(1): 88-92.


OBJECTIVE To compare rates of lymph node dissection (LND) and nodal yields between patients treated with open radical retropubic prostatectomy (ORRP) and robot-assisted RRP (RARP) in a contemporary single-institution series. PATIENTS AND METHODS Data from 1278 consecutive patients (716 ORRP and 562 RARP) from one institution were accrued prospectively in an institutional database, and the data analysed retrospectively. Disease risk was assessed using the Cancer of the Prostate Risk Assessment (CAPRA) score. The likelihood of LND, nodal yield, and likelihood of node positivity were compared between ORRP and RARP. RESULTS Of patients treated with ORRP and RARP, 47.8% and 31.8% had LND, respectively, with more receiving LND over time in both surgical approaches. Men undergoing LND had a higher disease risk than those not undergoing LND (mean CAPRA score 4.3 vs 2.1, P < 0.01), and there was no difference in risk between those undergoing ORRP or RARP (mean CAPRA score 3.0 vs 2.9, P = 0.29). The mean (sd) nodal yield was 14.4 (8.7) for ORRP and 9.3 (5.4) for RARP (P < 0.01). Among patients undergoing LND, 5.8% of ORRP and 4.1% of RARP patients had positive nodes (P < 0.01). CONCLUSIONS The indications for LND and template dissection should be the same regardless of surgical approach. The nodal yield was adequate using both approaches; the yield was higher among ORRP than RARP patients, but the difference was not large, and is less remarkable than the wide variation in yield within each approach. Several factors might explain this variation. © 2009 BJU International.




“Prophylaxis of erectile function after radical prostatectomy with phosphodiesterase type 5 inhibitors.”

Deho, F., A. Gallina, et al. (2009).

Current Pharmaceutical Design 15(30): 3496-3501.


Erectile dysfunction (ED) is one of the most challenging complications associated with radical prostatectomy (RP) for clinically localized prostate cancer. Currently, a broad spectrum of therapeutic options are available to improve sexual health after surgical treatment. Several basic science reports highlighted a potential role for phosphodiesterase type 5 inhibitors in the prevention of endothelial damage related to ischemia reperfusion and/or denervation following surgery. Recent studies have shown that pharmacological prophylaxis soon after RP can significantly improve the rate at which erectile function is recovered after surgery. Use of on-demand treatments for ED in patients who have undergone RP has been shown to be highly effective. In this context, pharmacological prophylaxis potentially may have a significantly expanded role in future strategies aimed at preserving postoperative erectile function. We analyzed the factors affecting erectile function after RP and evaluated the evidence suggesting the role of pharmacological prophylaxis and treatment of ED after surgery. © 2009 Bentham Science Publishers Ltd.




“Robotic Assisted Laparoscopic Salvage Prostatectomy for Radiation Resistant Prostate Cancer.”

Eandi, J. A., B. A. Link, et al. (2010).

Journal of Urology 183(1): 133-137.


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.




“Double-pigtail stenting of the ureters: technique for securing the ureteral orifices during robot-assisted radical prostatectomy for large median lobes.”

El Douaihy, Y., G. Y. Tan, et al. (2009).

J Endourol 23(12): 1975-1977.


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 prostatectomy: The new standard of care or a marketing success?”

Estey, E. P. (2009).

Can Urol Assoc J 3(6): 488-490.




“Arguments against investing widely in robotic prostatectomy in Canada: a wrong focus on tool box rather than surgical expertise.”

Fradet, Y. (2009).

Can Urol Assoc J 3(6): 486-487.




“Urinary and sexual outcomes in long-term (5+ years) prostate cancer disease free survivors after radical prostatectomy.”

Gacci, M., A. Simonato, et al. (2009).

Health and Quality of Life Outcomes 7.


Background: After long term disease free follow up (FUp) patients reconsider quality of life (QOL) outcomes. Aim of this study is assess QoL in prostate cancer patients who are disease-free at least 5 years after radical prostatectomy (RP). Methods: 367 patients treated with RP for clinically localized pCa, without biochemical failure (PSA ≤ 0.2 ng/mL) at the follow up ≥ 5 years were recruited. Results: Urinary (UF) and Sexual Function (SF), Urinary (UB) and Sexual Bother (SB) were assessed by using UCLA-PCI questionnaire. UF, UB, SF and SB were analyzed according to: treatment timing (age at time of RP, FUp duration, age at time of FUp), tumor characteristics (preoperative PSA, TNM stage, pathological Gleason score), nerve sparing (NS) procedure, and hormonal treatment (HT). Conclusion: We calculated the differences between 93 NS-RP without HT (group A) and 274 non-NS-RP or NS-RP with HT (group B). We evaluated the correlation between function and bother in group A according to follow-up duration. Time since prostatectomy had a negative effect on SF and a positive effect SB (both p < 0.001). Elderly men at follow up experienced worse UF and SF (p = 0.02 and p < 0.001) and better SB (p < 0.001). Higher stage PCa negatively affected UB, SF, and SB (all: p ≤ 0.05). NS was associated with better UB, SF and SB (all: p ≤ 0.05); conversely, HT was associated with worse UF, SF and SB (all: p ≤ 0.05). More than 8 years after prostatectomy SF of group A and B were similar. Group A subjects (NS-RP without HT) demonstrated worsening SF, but improved SB, suggesting dissociation of the correlation between SF and SB over time. Older age at follow up and higher pathological stage were associated with worse QoL outcomes after RP. The direct correlation between UF and age at follow up, with no correlation between UF and age at time of RP suggests that other issues (i.e: vascular or neurogenic disorders), subsequent to RP, are determinant on urinary incontinence. After NS-RP without HT the correlation between SF and SB is maintained for 7 years, after which function and bother appear to have divergent trajectories. © 2009 Gacci et al; licensee BioMed Central Ltd.




“Robot-assisted radical prostatectomy in men aged ≥70 years.”

Greco, K. A., J. J. Meeks, et al. (2009).

BJU International 104(10): 1492-1495.


OBJECTIVES To assess the outcomes of elderly men with prostate cancer treated with robot-assisted radical prostatectomy (RARP), because more healthy elderly men will present with localized prostate cancer and many will seek surgical treatment as the population ages. PATIENTS AND METHODS Between 2005 and 2008, 203 men had RARP performed by one surgeon; patients were categorized into two groups based on their age (≥70 vs <70 years). All data were recorded prospectively in an institutional approved database. RESULTS Of the 203 men, 23 (11%) were aged ≥70 years; the older men had similar baseline characteristics as younger men, and had characteristics during and after surgery comparable to those in younger men. The pathological RARP Gleason grade was significantly greater in older men. Surgical complications were not significantly different between the groups. Continence rates were significantly lower in older men at 6 months after surgery, but returned to levels equivalent to those in younger men within 12 months after surgery. Older patients took significantly longer to be capable of driving after surgery. CONCLUSIONS The outcomes of RARP in elderly men are largely comparable to those in younger men, with the exception of higher pathological Gleason grade, a transient delay in return of continence, and taking longer to return to driving after surgery. Advanced chronological age should not be a contraindication for RARP in patients with clinically localized prostate cancer, but expectations should be managed preoperatively. © 2009 BJU International.




“Effects of thoracic epidural analgesia combined with general anesthesia on intraoperative Ventilation/Oxygenation and postoperative pulmonary complications in robot-assisted laparoscopic radical prostatectomy.”

Hong, J. Y., S. J. Lee, et al. (2009).

Journal of Endourology 23(11): 1843-1849.




Purpose: The purpose of this study was to evaluate the effects of thoracic epidural analgesia (TEA) on intraoperative ventilation/oxygenation and postoperative pulmonary complications in robot-assisted laparoscopic radical prostatectomy requiring high-pressure pneumoperitoneum and the extreme head-down position. Methods: Seventy-two patients (age range, 58-76 years) scheduled for elective robot-assisted laparoscopic radical prostatectomy were randomly assigned to receive either TEA combined with general anesthesia (TEA group, n=36) or general anesthesia (GA group, n=36). T4-sensory block using 1% lidocaine was continuously provided during surgery in the TEA group but not in the GA group. The mode of ventilation was volume controlled with a linear ramp in the pressure wave. Maximum peak inspiratory pressure was preset at 35mm Hg, and no positive end-expiratory pressure was administered to the patients. Minute ventilation was adjusted to maintain end-tidal CO2 between 30 and 35mm Hg by changing respiratory rate during surgery. Intraoperative ventilatory parameters and blood gas analyses were checked. Clinical and radiological pulmonary complications were observed for 3 days postoperatively. Results: Patients in the TEA group showed significantly lower peak inspiratory pressure and higher dynamic compliance with larger expiratory tidal volume during surgery than those in the GA group. They had significantly better oxygenation and lower concentrations of lactate on arterial blood gas analysis than the GA group. Postoperative clinical and radiological complication rates were not significantly different. Conclusions: TEA combined with general anesthesia improved intraoperative ventilation/oxygenation. Although clinical and radiologic pulmonary complications were not significantly influenced, TEA can be considered an option for patients with limited reserve capacity or preexisting impairments of visceral blood flow. © 2009 Mary Ann Liebert, Inc.




“Why I Perform Robotic-Assisted Laparoscopic Radical Prostatectomy, Despite More Incontinence and Erectile Dysfunction Diagnoses Compared to Open Surgery: It’s Not About the Robot.”

Hu, J. C. (2009).

European Urology.




“Robot-assisted laparoscopic prostatectomy performed in a patient with severe thrombocytopenia due to primary myelofibrosis.”

Khavari, R., L. Stamatakis, et al. (2009).

Journal of the Canadian Urological Association 3(4).


Robot-assisted laparoscopic prostatectomy (RALP) has emerged as a minimally invasive alternative to open radical prostatectomy (ORP) for the treatment of clinically localized prostate cancer. In comparison to the open procedure, there is significantly less intraoperative blood loss during RALP. This benefit has allowed RALP to become a feasible option for patients who would be poor candidates for ORP, including those patients with intrinsic hematological disorders. In this case study, we report a successfully performed RALP in a patient with severe thrombocytopenia in the presence of primary myelofibrosis. © 2009 Canadian Urological Association.




“Posterior and anterior fixation of the urethra during robotic prostatectomy improves early continence rates.”

Koliakos, N., A. Mottrie, et al. (2009).

Scand J Urol Nephrol.


Abstract Objective. To investigate whether posterior and anterior fixation of the vesicourethral anastomosis during robotic radical prostatectomy (RRP) helps to establish continence earlier. Material and methods. Forty-seven consecutive patients undergoing RRP were randomized into two groups. The first group received a typical Van Velthoven vesicourethral anastomosis and the second group a modified anastomosis with posterior and anterior fixation. In this group the posterior fibrous tissues of the sphincter were sutured to the residual Denonvilliers’ fascia. The anastomosis with two running sutures started at the 6 o’clock position on the bladder neck and continued upwards. Two-step stitching was done on the upper half of the anastomosis to ensure good stabilization of the bladder: a small portion of urethral stump followed by a deep haemostatic stitch on the plexus. Continence, as measured by patient self-reporting of the number of pads used per 24 h, was assessed 7 weeks after catheter removal, by telephone interview. The use of no pads or one pad was defined as “continent”, two pads as “moderate incontinence” and more than two pads as “severe incontinence”. Results. At catheter removal, more patients in the fixation group were continent than in the Van Velthoven group [9/23 (39%) vs 3/24 (12.5%), p = 0.036]. At 7 weeks, continence was even better in the fixation group [15/23 (65%) vs 8/24 (33%), p = 0. 029]. The mean pad usage was less in the fixation group (1.43 vs 2.25, p = 0.032). Conclusions. The posterior and anterior fixation of the vesicourethral anastomosis during RRP results in an intact sphincteric mechanism, because no stretch is applied to the urethra, resulting in earlier continence.




“Interval from prostate biopsy to robot-assisted radical prostatectomy: Effects on perioperative outcomes.”

Martin, G. L., R. N. Nunez, et al. (2009).

BJU International 104(11): 1734-1737.


Objective To determine whether shorter intervals (<4 and 6 weeks) between prostate biopsy and robot-assisted radical prostatectomy (RARP) have a detrimental effect on perioperative outcomes, as recent studies showed that open RP shortly after prostate biopsy does not adversely influence surgical difficulty or efficacy, but RARP relies solely on visual cues rather than tactile sensation to determine posterior surgical planes of dissection. Patients and methods A series of 559 patients undergoing RARP from March 2004 to July 2007 was retrospectively reviewed. The interval between prostate biopsy and RARP was determined and patients with intervals of ≤4 weeks were compared to those >4 weeks. Patient characteristics and perioperative outcomes were analysed to determine statistically significant differences between the groups. This comparison was then repeated with a ≤6- vs >6-week interval, and examined with a multivariate logistic regression analysis. Results In the ≤4-week group (27 patients) vs the >4-week group (509 patients), there was a significantly (P < 0.05) higher rate of complications (18.5% vs 6.9%). In the ≤6-week group (81 patients) vs the >6-week group (455 patients) there was a smaller but still significantly higher rate of complications (13.6% vs 6.4%). These results were still significant when controlling for patient and disease characteristics and the ‘learning curve’. There was also a significantly higher rate of transfusion in the ≤6-week group (3.7%) than the >6-week group (0.7%). Conclusions Our data suggest that RARP should be delayed after prostate biopsy; RARP within 6 weeks of biopsy was associated with a greater risk of complications even when controlling for disease and patient characteristics. © 2009 BJU INTERNATIONAL.




“An analysis of sexual health information on radical prostatectomy websites.”

Mulhall, J. P., C. Rojaz-Cruz, et al. (2010).

BJU International 105(1): 68-72.


OBJECTIVE To define the nature of information posted on websites related to radical prostatectomy (RP), specifically its accuracy and comprehensiveness, as RP is associated with erectile dysfunction (ED). METHODS We reviewed 70 robotic RP (RARP) and 20 open RP (ORP) medical centres. Their websites were reviewed for various factors, by two separate reviewers whose reviews were not seen by each other. Websites were graded based on accuracy and comprehensiveness of information by the senior investigator. RESULTS Of the academic and community-based RARP centres, 55% and 79% had specific websites (P < 0.05); 45% of RARP sites had generic information copied directly from the website of Intuitive Surgical (Sunnyvale, CA, USA; the manufacturer of the robotic system). ED was mentioned by only 54% of RARP sites and 45% of ORP sites; 17% of RARP sites were deemed accurate, compared with 30% of ORP sites (P < 0.05). Just over 1% of RARP sites were considered comprehensive, vs 10% of ORP sites (P < 0.05). A third of RARP sites had a direct link to the Intuitive Surgical website (16% academic vs 53% community, P < 0.05), compared to 10% of open sites (P < 0.05). Of most interest was that half of the RARP sites suggested that ED rates were lower for RARP than for ORP; this compared to ED rates being cited as lower for ORP on 5% of the ORP sites (P < 0.05). CONCLUSIONS Despite the stature of RP as a treatment option for men with prostate cancer, and the recent increase in the use of RARP, the accuracy of information pertaining to sexual health on RP websites is poor, with many making false statements about the long-term outcomes for erectile function. This inadequacy appears to be greater on RARP than on ORP websites. © 2009 BJU International.




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

Murphy, D. G., A. Bjartell, et al. (2009).

Eur Urol.


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.




“Is the transition from open to robotic prostatectomy fair to your patients? A single-surgeon comparison with 2-year follow-up.”

Nadler, R. B., J. T. Casey, et al. (2009).

Journal of Robotic Surgery: 1-7.


Robot-assisted radical prostatectomy (RARP) is a procedure thought to require experience with a significant number of cases before mastering. Most RARP series examine outcomes after the learning curve or by combining results from multiple surgeons. We review a single surgeon’s experience during the transition from open radical retropubic prostatectomy (RRP) to RARP using a matched case-control model. We prospectively analyzed 50 RARP cases and made comparison with the last 50 consecutive RRP cases. Operative time was longer for RARP than RRP (341 versus 235 min, p < 0.01), and mean estimated blood loss was less for RARP than RRP (533 versus 1,540 ml, p < 0.01). There was a trend towards fewer positive surgical margins (PSM) for RARP (10%) than RRP (24%; p = 0.06). High-risk patients were found to have a greater percentage of PSM following RRP (70%) in comparison with RARP (17%; p = 0.04). The number of patients who experienced complications was no different between groups (16 versus 12, p = 0.37). Erectile function at 12, 18, and 24 months showed no difference between groups (p = 0.15, 0.92, and 0.23, respectively). There was no difference in continence at 1 year (88.6% versus 89.1%; p = 0.94). During 27.1 months of follow-up for the RARP group and 30.4 months for the RRP group, 92% and 94% of patients had an undetectable prostate-specific antigen (PSA) (defined as ≤0.1), respectively (p = 0.38). We report similar outcomes in patients undergoing RARP by a surgeon transitioning from RRP to RARP, confirming that the learning curve does not affect patient outcomes over a 2-year follow-up. © 2009 Springer-Verlag London Ltd.




“Prospective Evaluation With Standardised Criteria for Postoperative Complications After Robotic-Assisted Laparoscopic Radical Prostatectomy.”

Novara, G., V. Ficarra, et al. (2009).

European Urology.


Background: Very few studies have evaluated the risk of complications following robotic-assisted laparoscopic radical prostatectomy (RARP), and all were flawed by several methodological biases. Objective: To evaluate the prevalence of early complications and risk factors following RARP, reporting complications in agreement with the standardised Martin criteria. Design, setting, and participants: All 415 patients who underwent surgery for clinically localised prostate cancer from April 2005 to April 2009 at a single tertiary academic centre were prospectively studied. Intervention: RARP was performed by two surgeons with the same technique. Measurements: Complications were collected and reported according to the standardised Martin criteria. Results and limitations: One hundred and two complications were observed in 90 patients (21.6%), with bleeding (5.3%), lymphorrhoea (4.3%), and pelvic haematoma (2.4%) the most common ones. According to the modified Clavien system, 41 patients (10%) had grade 1, 37 (9%) had grade 2, 11 (3%) had grade 3, and 1 (0.2%) had grade 4 complications. On multivariable analysis, prostate volume (odds ratio: 0.985; p < 0.001) and the number of cases performed (p < 0.001) were independent predictors of the occurrence of any grade complications. Considering grade 3 to 4 complications, only the number of cases performed by the surgeons was significantly associated with major complications in a univariable analysis (p < 0.001). The major limitation of the study is represented by the relatively small number of patients and events included in the analysis, resulting in the study being underpowered to identify some factors predicting any or high-grade complications. Conclusions: Applying standardised criteria to collect and report complications, we identified early complications in about 22% of our patients undergoing RARP. Although most of the patients experienced minor complications, 3% of them did experience grade 3 or 4 complications. Prostate volume and number of RARP performed by the surgeons were independent predictors of the occurrence of complications. © 2009.




“Intraoperative drug-eluting stent thrombosis in a patient undergoing robotic prostatectomy.”

Sharma, A. and A. Berkeley (2009).

Journal of Clinical Anesthesia 21(7): 517-520.


Insertion of drug-eluting stents is one of the strategies for treating patients with coronary artery disease. These patients can be a perioperative challenge in management as they need to be maintained on antiplatelet therapy to prevent stent thrombosis, which puts them at an increased risk for surgical bleeding. Recently revised guidelines on elective surgery following insertion of a drug-eluting stent recommend dual antiplatelet therapy for a period of twelve months. The management of a patient who presented for surgery more than two years after the insertion of a drug-eluting stent, and who developed in-stent thrombosis intraoperatively, is presented. © 2009 Elsevier Inc. All rights reserved.




“Delayed infection of a pelvic lymphocele following robotic radical prostatectomy and pelvic lymphadenectomy: Two cases.”

Tremp, M., T. Sulser, et al. (2009).

Urologia Internationalis 83(4): 479-481.


Pelvic lymphocele is an infrequent complication of pelvic surgery, usually presenting shortly after surgery. We report 2 cases with a delayed infected pelvic lymphocele presenting after transperitoneal pelvic lymphadenectomy and robotic radical prostatectomy for adenocarcinoma of the prostate. These cases illustrate that late infection of pelvic lymphoceles may occur following radical prostatectomy and pelvic lymphadenectomy. The practicing urologist should be aware of this possibility and look for an infected lymphocele in postoperative pelvic lymphadenectomy patients presenting with fever and leukocytosis of uncertain etiology, regardless of the time elapsed since surgery. To date, there is a paucity of data in the literature on robotic- assisted laparoscopic resection of a lymphocele after radical prostatectomy. The minimally invasive technique can be considered as a possible alternative to lymphocele percutaneous drainage. It is effective, results in minimal patient morbidity and allows for rapid recovery. © 2009 S. Karger AG, Basel.