“Recent advances in robot-assisted radical cystectomy.”
Cha, E. K., N. P. Wiklund, et al. (2011).
Current Opinion in Urology21(1): 65-70.
PURPOSE OF REVIEW: The prevalence of robot-assisted radical cystectomy is steadily increasing. We review the recent literature evaluating this technique as a minimally invasive alternative to open radical cystectomy for the treatment of bladder cancer. RECENT FINDINGS: Within the last year, numerous robot-assisted radical cystectomy case series with larger cohorts have been published, providing new insights regarding perioperative morbidity and early oncologic outcomes. With appropriate experience, this procedure offers the potential benefits of decreased blood loss and transfusion rates, reduced analgesic requirements, and shorter hospital stay relative to the open approach. Recent data from a nonrandomized study demonstrate fewer postoperative complications with robot-assisted radical cystectomy. Short-term oncologic outcomes in the absence of patient selection appear to be equivalent to contemporary open radical cystectomy series. A small prospective, randomized trial comparing open and robotic radical cystectomy demonstrated equivalent lymph node yields. SUMMARY: Robot-assisted radical cystectomy is an emerging minimally invasive approach to radical cystectomy. Early data suggest potential benefits in perioperative morbidity with equivalent short-term oncologic outcomes as compared with open radical cystectomy. Long-term follow-up and larger prospective, randomized comparisons with open radical cystectomy are needed as this technique continues to be evaluated.
“Is patient outcome compromised during the initial experience with robot-assisted radical cystectomy? Results of 164 consecutive cases.”
Hayn, M. H., N. J. Hellenthal, et al. (2010).
Study Type – Therapy (case series)Level of Evidence 4 OBJECTIVE: Robot-assisted radical cystectomy (RARC) remains controversial in terms of oncologic outcomes, especially during the initial experience. The purpose of this study was to evaluate the impact of initial experience of robotic cystectomy programs on oncologic outcomes and overall survival. PATIENTS AND METHODS: Utilizing a prospectively maintained, single institution robotic cystectomy database, we identified 164 consecutive patients who underwent RARC since November 2005. After stratification by age group, gender, pathologic T stage, lymph node status, surgical margin status, and sequential case number; we used chi-squared analyses to correlate sequential case number to operative time, surgical blood loss, lymph node yield, and surgical margin status. We also addressed the relationship between complications and sequential case number. We then utilized Cox proportional hazard modeling and Kaplan-Meier survival analyses to correlate variables to overall mortality. RESULTS: Sequential case number was not significantly associated with increased incidence of complications, surgical blood loss, or positive surgical margins (P= 0.780, P= 0.548, P= 0.545). Case number was, however, significantly associated with shorter operative time and mean number of lymph nodes retrieved (P < 0.001, P < 0.001). Sequential case number was not significantly associated with survival; however, tumor stage, the presence of lymph node metastases, and positive surgical margins were significantly associated with death. Although being the largest of its kind, this was a small study with short follow-up when compared to open cystectomy series. CONCLUSION: Initial experience with RARC did not affect the incidence of positive surgical margins, operative/postoperative complications, or overall survival in a single-institution series.
“Robotic radical anterior pelvic exenteration: The UCI experience.”
Kaufmann, O. G., J. L. Young, et al. (2010).
Minim Invasive Ther Allied Technol.
Abstract Robotic technology may be a promising tool in reduction of morbidity in radical anterior pelvic exenteration for invasive bladder cancer. We report our initial experience with robotic-assisted radical anterior pelvic exenteration in females in an attempt to evaluate the technique’s feasibility and outcomes. A retrospective review of our bladder cancer database was performed. Twelve women that underwent robotic-assisted radical anterior pelvic exenteration, bilateral pelvic lymphadenectomy, and urinary diversion for clinically localized urothelial carcinoma of the bladder between 2004 and 2008 were included in this retrospective study. Median age was 73.0 +/- 9.6 years and median body mass index (BMI) was 23.5 +/- 5.0 kg/m(2). Ten patients underwent ileal conduit diversion, one had an orthotopic neobladder and one an Indiana pouch. Median total operating time was 6.4 +/- 1.5 hours with median console and diversion times of 4.7 +/- 0.9 and 2.5 +/- 1.5 hours respectively. Median blood loss was 275.0 +/- 165.8 ml. Median length of stay was 8.0 +/- 1.6 days. Four patients were T2N0 or less, five T3N0, one T3N1 and two patients T4N0. There was one patient with positive surgical margins. Median number of lymph nodes removed was 23.0 +/- 11.4. Median follow-up of 9.0 +/- 6.0 months was available for ten patients. One had a recurrent ureteroenteric stricture, one had colpocleisis for vault prolapse, and three had metastatic disease. Robotic-assisted laparoscopic anterior pelvic exenteration appears to be a favorable surgical option with acceptable operative, pathological, and short-term clinical outcomes. According to the UCI experience, robotic anterior exenteration appears to achieve the clinical and oncologic goals for the surgical treatment of bladder cancer.
“Robot-assisted Radical Cystectomy Versus Open Radical Cystectomy: A Complete Cost Analysis.”
Martin, A. D., R. N. Nunez, et al. (2010).
OBJECTIVES: To perform a complete cost analysis comparing robot assisted radical cystectomy (RARC) versus open radical cystectomy (ORC). MATERIAL AND METHODS: After institutional review board approval for data collection, we prospectively recorded perioperative outcomes and costs, such as hospital stay, transfusion rate, readmission rate, and medications for consecutive patients undergoing RARC or ORC. Using actual cost data, we developed a cost decision tree model to determine typical perioperative costs for both RARC and ORC. Multivariate sensitivity analysis was performed to elucidate which variables had the greatest impact on overall cost. Breakeven points with ORC were calculated using our model to better evaluate variable influence. In addition to the above modeled analysis, actual patient costs, including complications 30 days from surgery, were also compared for each procedure. RESULTS: Our model analysis showed that operative time and length of stay had the greatest impact on perioperative costs. Robotic cystectomy became more expensive than open cystectomy at the following break-even points: operating room (OR) time greater than 361 minutes, length of stay greater than 6.6 days, or robotic OR supply cost exceeding $5853. RARC was 16% more expensive when only comparing direct operative costs. Interestingly, actual total patient costs revealed a 38% cost advantage favoring RARC due to increased hospitalization costs for ORC in our cohort. CONCLUSIONS: RARC can provide a cost-effective alternative to ORC with operative time and length of stay being the most critical cost determinants. Higher complication rates with ORC make total actual costs much higher than RARC.
“Ileovesicostomy for the Neurogenic Bladder Patient: Outcome and Cost Comparison of Open and Robotic Assisted Techniques.”
Vanni, A. J. and J. T. Stoffel (2010).
OBJECTIVES: To compare the outcomes and cost of open and robotic-assisted ileovesicostomy techniques for the adult neurogenic bladder patient. METHODS: Consecutive open and robotic-assisted ileovesicostomy procedures were retrospectively reviewed for demographic, operative, and postoperative recovery data. Surgical outcome was assessed by examining the incidence of postprocedure urinary incontinence, urinary tract infections (UTIs), and upper tract compromise. Total cost was calculated through summation of inpatient costs, including room/board, operating/recovery room, surgical supplies, professional fees, intensive care unit, and robotic maintenance. RESULTS: Fifteen ileovesicostomy procedures (7 open, 8 robotic) were reviewed. Both groups had similar demographic and urodynamic data. Operative times (293 min open vs 330 min robotic, P = .24) were similar between techniques. There were trends toward lower operative blood loss (100 mL vs 257 mL, P = .09) and shorter hospital stays in the robotic group (8 days vs 11 days, P = .14). Ileovesicostomy was associated with improved urinary continence (P = .02) and trended toward a decreased incidence of postoperative chronic UTI (P = .13) for the entire group, and there was no difference between techniques regarding continence, chronic UTIs, and complications. No patients in either group developed postoperative hydronephrosis. Total inpatient cost for the open and robotic groups was $14,356 and $17,344 (P = .05), which differed primarily because of higher robotic operating room supply costs ($609 vs $3770, P <.001). CONCLUSION: Robotic and open ileovesicostomy had similar surgical outcomes in this patient cohort, although total inpatient costs were significantly higher in the robotic group.
“Kidney Deformation and Intraprocedural Registration: A Study of Elements of Image-Guided Kidney Surgery.”
Altamar, H. O., R. E. Ong, et al. (2010).
Journal of Endourology.
Abstract Introduction: Central to any image-guided surgical procedure is the alignment of image and physical coordinate spaces, or registration. We explored the task of registration in the kidney through in vivo and ex vivo porcine animal models and a human study of minimally invasive kidney surgery. Methods: A set of (n = 6) ex vivo porcine kidney models was utilized to study the effect of perfusion and loss of turgor caused by incision. Computed tomography (CT) and laser range scanner localizations of the porcine kidneys were performed before and after renal vessel clamping and after capsular incision. The da Vinci robotic surgery system was used for kidney surface acquisition and registration during robot-assisted laparoscopic partial nephrectomy. The surgeon acquired the physical surface data points with a tracked robotic instrument. These data points were aligned to preoperative CT for surface-based registrations. In addition, two biomechanical elastic computer models (isotropic and anisotropic) were constructed to simulate deformations in one of the kidneys to assess predictive capabilities. Results: The mean displacement at the surface fiducials (glass beads) in six porcine kidneys was 4.4 +/- 2.1 mm (range 3.4-6.7 mm), with a maximum displacement range of 6.1 to 11.2 mm. Surface-based registrations using the da Vinci robotic instrument in robot-assisted laparoscopic partial nephrectomy yielded mean and standard deviation closest point distances of 1.4 and 1.1 mm. With respect to computer model predictive capability, the target registration error was on average 6.7 mm without using the model and 3.2 mm with using the model. The maximum target error reduced from 11.4 to 6.2 mm. The anisotropic biomechanical model yielded better performance but was not statistically better. Conclusions: An initial point-based alignment followed by an iterative closest point registration is a feasible method of registering preoperative image (CT) space to intraoperative physical (robot) space. Although rigid registration provides utility for image-guidance, local deformations in regions of resection may be more significant. Computer models may be useful for prediction of such deformations, but more investigation is needed to establish the necessity of such compensation.
“Comparison of Robot-assisted Versus Conventional Laparoscopic Transperitoneal Pyeloplasty for Patients With Ureteropelvic Junction Obstruction: A Single-center Study.”
Bird, V. G., R. J. Leveillee, et al. (2010).
OBJECTIVES: To compare conventional laparoscopic pyeloplasty (C-LPP) and robotic-assisted laparoscopic pyeloplasty (RA-LPP), which are both used for correction of ureteropelvic junction obstruction. Robotic assistance may further expedite dissection and reconstruction; however it is unclear whether this has an impact on results. METHODS: Between 1999 and 2009, 172 conventional or robotic-assisted transperitoneal laparoscopic pyeloplasties were performed by 2 surgeons. Data were obtained from our prospective database, patient charts, and radiographic reports. Statistical analysis was performed for the groups. RESULTS: A total of 98 patients underwent R-LPP, and 74 underwent C-LPP. Mean age, body mass index, and gender distribution were similar for the groups. Of the patients, 22 (12.8%) had secondary ureteropelvic junction obstruction. Operative time in minutes was 189.3 +/- 62 for RA-LPP, and 186.6 +/- 69 for C-LPP (P = .69) respectively. Intraoperative and postoperative complication rates for RA-LPP and C-LPP were 1%, 5.1% and 0, 2.7% (P = .83 and .85) respectively. There was no significant difference in mean suturing time: 48.3 +/- 30 and 60 +/- 46 (P = .30) for RA-LPP and C-LPP, respectively. Long-term follow up (minimum 6 months; available for 136 patients) showed 93.4% and 95% radiographic success rate based upon diuretic scintirenography for RA-LPP and C-LPP respectively. CONCLUSIONS: Operative time, perioperative outcome and success rates are similar for C-LPP and RA-LPP. Mean suturing time for RA-LPP was shorter; however, there was no significant time difference in total operative time. Complications for both procedures are infrequent. Success rates, as measured by diuretic scintirenography, are high for the 2 procedures.
“Multi-Institutional Analysis of Robotic Partial Nephrectomy for Hilar Versus Nonhilar Lesions in 446 Consecutive Cases.”
Dulabon, L. M., J. H. Kaouk, et al. (2010).
Background: Minimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon. Objective: We compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients. Design, setting, and participants: We retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions. Measurements: Patient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded. Results and limitations: Forty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2 cm vs 2.6 cm; p = 0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3 ± 7.4 min vs 19.6 ± 10.0 min; p = <0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons’ prior robotic experience. Conclusions: The data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons. © 2010.
“Innovations in laparoscopic and robotic partial nephrectomy: a novel ‘zero ischemia’ technique.”
Eisenberg, M. S., M. B. Patil, et al. (2010).
Current Opinion in Urology.
PURPOSE OF REVIEW: To describe a novel ‘zero ischemia’ technique for laparoscopic and robotic partial nephrectomy. RECENT FINDINGS: Laparoscopic partial nephrectomy has been performed in 15 patients without the need for warm ischemia by utilizing pharmalogically induced hypotension. This consecutive series includes complex tumors in patients with multiple comorbidities. Herein we describe our current practice, initial results, and several practical considerations associated with the application of this novel technique. SUMMARY: Initial results with our ‘zero ischemia’ technique have been encouraging. Evaluation of long-term outcomes is ongoing.
“Robotic partial nephrectomy in the setting of prior abdominal surgery.”
Petros, F. G., M. N. Patel, et al. (2010).
Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE: To evaluate our experience with robotic partial nephrectomy in patients with previous abdominal surgery and evaluate the effect of previous abdominal surgery on perioperative outcomes. We also describe a technique for intraperitoneal access for patients with prior abdominal surgery utilizing the 8 mm robotic camera for direct-vision trocar placement. PATIENTS AND METHODS: From a prospective cohort of 197 consecutive patients who underwent robotic renal surgery at a single academic institution, a total of 95 patients underwent transperitoneal robotic partial nephrectomy (RPN). Patients with and without previous abdominal surgery were compared. Patients with prior abdominal surgery were subcategorized into two groups: upper midline or ipsilateral upper quadrant scar or lower abdominal, contralateral, or minimally-invasive scar. Demographic and perioperative variables were compared between the surgery and no surgery groups. Access was obtained using a Veress needle or Hassan technique. We utilized a technique of direct vision placement of the initial trocar on our 10 most recent cases, using an 8 mm robotic camera placed through the obturator of 12 mm clear-tipped trocar. Lysis of adhesions was performed as needed to allow for placement of additional robotic ports. RESULTS: A total of 95 patients underwent transperitoneal RPN, of which 41 (43%) had a history of prior abdominal surgery and six had upper midline or ipsilateral upper quadrant scars. There were no statistically significant differences between patients with previous abdominal surgery and patients with no previous abdominal surgery in BMI (30.4 vs 29.4 kg/m(2) ), median tumor size (2.5 cm vs 2.3), median total operative time (246 vs 250 min), median warm ischemia time (21 vs 16 min), median EBL (150 vs100 ml), clinical stage, transfusion rate, or complications. A total of six patients underwent 7 previous upper midline or ipsilateral upper quadrant surgeries, including open cholecystectomy-2 patients (33%), open partial gastrectomy-2 patients (33%) and exploratory laparotomy-1 patient (17%). Complications in this group were an enterotomy during lysis of adhesions that was repaired robotically without sequelae and a mesenteric hematoma during Veress needle placement. A total of 35 patients underwent 16 other prior abdominal surgeries, including abdominal hysterectomy-10 patients (29%), umbilical/inguinal hernia repair-9 patients (26%) and appendectomy-7 patients (20%). There were no access related injuries in the 10 cases in which the robotic 8 mm camera was used for initial trocar placement. CONCLUSIONS: Transperitoneal robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. The majority of these patients can have their procedure performed safely without an increase in complications. Direct-vision intraperitoneal placement of initial trocar may be achieved by using an 8 mm robotic camera, without the need to switch between conventional and robotic cameras.
“Robotic-assisted laparoscopic donor nephrectomy with transvaginal extraction of the kidney.”
Pietrabissa, A., M. Abelli, et al. (2010).
American Journal of Transplantation10(12): 2708-2711.
Transvaginal recovery of the kidney has recently been reported, in a donor who had previously undergone a hysterectomy, as a less-invasive approach to perform laparoscopic live-donor nephrectomy. Also, robotic-assisted laparoscopic kidney donation was suggested to enhance the surgeon’s skills during renal dissection and to facilitate, in a different setting, the closure of the vaginal wall after a colpotomy. We report here the technique used for the first case of robotic-assisted laparoscopic live-donor nephrectomy with transvaginal extraction of the graft in a patient with the uterus in place. The procedure was carried out by a multidisciplinary team, including a gynecologist. Total operative time was 215 min with a robotic time of 95 min. Warm ischemia time was 3 min and 15 s. The kidney was pre-entrapped in a bag and extracted transvaginally. There was no intra- or postoperative complication. No infection was seen in the donor or in the recipient. The donor did not require postoperative analgesia and was discharged from the hospital 24 h after surgery. Our initial experience with the combination of robotic surgery and transvaginal extraction of the donated kidney appears to open a new opportunity to further minimize the trauma to selected donors.
“Kidney removal the past, presence, and perspectives: A historical review.”
Poletajew, S., A. A. Antoniewicz, et al. (2010).
Urology Journal7(4): 215-223.
More than 140 years have passed since the first documented planned nephrectomy. Throughout all these years, people gained significant knowledge on the renal functions and diseases, and what is more, the surgical workshop underwent considerable improvement. Initially, the kidney removal operations were performed due to ureterovaginal fistulas and renal lithiasis. Later, they were executed mainly in patients with renal tumors, whereas today, the number of these surgeries tend to decrease to the benefit of nephron sparing procedures. Current nephrectomies are more and more often performed in case of organ donation, what will probably remain the most significant indication for the kidney removal in close future. While the first surgeries were executed with classical surgical methods, nowadays, after years of studies concerning nephron sparing and minimally invasive operations, we can see surgeries carried out through natural body orifices with robotic assistance. In relation to simple surgical operation based on ligation of 3 tubular anatomic structures, we can perceive the true scope of the progress that occurred in surgery. The aim of this article is to present the evolution of indications and operating techniques utilized to remove the kidney in chronological aspect.
“Complications associated with patient positioning in urologic surgery.”
Akhavan, A., D. M. Gainsburg, et al. (2010).
The impact of patient positioning can be profound. Urological surgeons must often exercise strategic positioning in order to access retroperitoneal and pelvic organs. However, the potential for position-related morbidity, particularly peripheral neuropraxia and compartment syndrome can be substantial. The purpose of the following review is to summarize the current literature on positioning-related concerns as they pertain to the practicing urologist. To our knowledge, this is the first such review of its kind in the urological literature. © 2010 Elsevier Inc. All rights reserved.
“Randomized clinical trials presented at the world congress of endourology: How is the quality of reporting?”
Autorino, R., C. Borges, et al. (2010).
Journal of Endourology24(12): 2067-2073.
Purpose: To assess the quality of reporting of randomized conrolled trials (RCTs) presented in abstract form at the annual World Congress of Endourology (WCE) and evaluate their course of subsequent publication. Materials and Methods: All RCTs presented in abstract form at the 2004, 2005, and 2006 WCE annual meetings were identified for review. Quality of reporting was assessed by applying a standardized 14-item evaluation tool based on the Consolidated Standards for the Reporting of Trials (CONSORT) statement. The subsequent publication rate for the corresponding studies by scanning Medline was also evaluated. Appropriate statistical analysis was performed. Results: A total of 94 RCTs (3.5% of 2669) were identified for review: 21 in 2004, 36 in 2005, and 37 in 2006. Overall, 45 (47.3% of the total) were subsequently published as a full length indexed manuscript with a mean time to publication of 16.4±13.2 months. Approximately 61 (60%) identified the study design as RCT in the abstract title. None reported the method of randomization. In studies that reported blinding (seven, 11% of 62), five were double blinded and two single blinded. Adverse events were reported in 38% of cases. Only 10% of the abstracts complied fully with more than 10 items according to our CONSORT-based checklist, whereas the majority of them failed to comply with most of the CONSORT requirements. Conclusions: Although representing a small portion of the overall number of abstracts, there has been a steady increase of presentation of RCTs at the WCE over the assessed 3-year period. Most of the time they are recognized as RCTs in the abstract title. When applying the CONSORT criteria, necessary information to assess their methodologic quality is incomplete in some cases. Copyright © 2010, Mary Ann Liebert, Inc.
“Live surgical demonstrations in urology: Valuable educational tool or putting patients at risk?”
Challacombe, B., R. Weston, et al. (2010).
BJU International106(11): 1571-1574.
“Robot-assisted vasectomy reversal.”
De Wil, P. and A. Mottrie (2010).
Journal of Andrological Sciences17(2): 56-61.
“Robotic-Assisted Laparoscopic Anatomic Hepatectomy in China: Initial Experience.”
Ji, W. B., H. G. Wang, et al. (2010).
Annals of Surgery.
OBJECTIVE:: To assess the feasibility and safety of robotic-assisted laparoscopic anatomic hepatectomy. BACKGROUND:: The development of minimally invasive surgery has led to an increase in the use of laparoscopic hepatectomy. However, laparoscopic hepatectomy remains technically challenging and is not widely developed. Robotic surgery represents a recent evolution in minimally invasive surgery that is being used increasingly for complex minimally invasive surgical procedures. Herein, we report our initial experience with robotic-assisted laparoscopic anatomic hepatectomy in 13 consecutive patients. PATIENTS AND METHODS:: Between April and July 2009, 13 consecutive patients underwent robotic-assisted laparoscopic anatomic hepatectomies for benign and malignant hepatic diseases. Major hepatectomies were performed in 9 patients, left lateral sectionectomies in 4 patients. Eight major hepatectomies were for malignant diseases and 5 hepatectomies (1 left hepatectomy and 4 left lateral sectionectomies) were for benign diseases. All the robotic-assisted hepatectomy procedures were performed anatomically with hilum dissection. Prior to starting the parenchymal transaction, vascular control of the portal vessels was carried out whenever possible. These robotic-assisted laparoscopic anatomic hepatectomies were compared with 20 traditional laparoscopic hepatectomies and 32 open resections that were contemporaneous and cohort-matched. RESULTS:: All 13 robotic-assisted laparoscopic anatomic hepatectomies were performed successfully in the manner of pure laparoscopic resection. No conversion to laparotomy or hand-assisted laparoscopic resection occurred. Despite its longer operative time (338 minutes) and higher hospital cost ($12,046), robotic liver surgery compared favorably with traditional laparoscopic hepatectomy and open resection in blood loss (280 vs. 350, 470 mL), transfusion requirement (0 vs. 3 of 20, 4 of 32), use of the Pringle maneuver (0 vs. 3 of 20, 6 of 32) and overall operative complications (7.8% vs. 10%, 12.5%). Neither ascites nor transient hepatic decompensation occurred in the robotic group. The surgical margins in all 8 patients with malignant lesions were negative and as yet, no intrahepatic recurrences or metastases have been observed in the robotic group. The mean postoperative stay was shorter with the traditional laparoscopic procedure (5.2 days) than with robotic (6.7 days) or open surgery (9.6 days). Conversions from traditional laparoscopic to open and hand-assisted laparoscopic resection occurred in 2 patients (10.0%) who underwent right hemihepatectomy and left hepatectomy, respectively. CONCLUSIONS:: These preliminary results show that robotic-assisted laparoscopic anatomic hepatectomy is safe and feasible with a much lower complication and conversion rate than traditional laparoscopic hepatectomy or open resection. The robotic surgical system may broaden the indications for laparoscopic hepatactomy, and it enabled the surgeon to perform precise laparoscopic liver resection which required hylum dissection, hepatocaval dissection, endoscopic suturing, and microanastamosis. However, more long-term, evidence-based outcomes will be necessary to prove its efficacy, and further research on its cost-effectiveness is still required.
“ProMIS() Can Serve as a da Vinci((R)) Simulator-A Construct Validity Study.”
Jonsson, M. N., M. Mahmood, et al. (2010).
Journal of Endourology.
Abstract Purpose: The purpose of this study was to investigate if the ProMIS simulator could serve as a training platform for the da Vinci((R)) surgical system and if this constellation could prove construct validity. Materials and Methods: The da Vinci system was connected to the ProMIS simulator, which registered objective data concerning how the surgeon performed in the box environment related to time, path, and smoothness. Five experienced robotic surgeons passed four different surgical tasks with progressive difficulty. A novice group-constituted of 13 consultants and 6 residents, none of them with any previous experience in the da Vinci system-passed the same tasks and the data were compared with the results from the expert group. Results: A statistically significant difference between experts and novices was demonstrated in all tasks concerning time and smoothness. For the parameter path, significant difference was only noted in the more complex tasks. Conclusions: Our study showed that ProMis could differentiate between experienced robotic surgeons and novices, thereby proving construct validity. Smoothness appeared to be the most sensitive objective parameter in our study. Tasks with high complexity are recommended when designing the program for robotic training.
“Cost-effectiveness of robotic-assisted laparoscopic procedures in urologic surgery in the USA.”
Sleeper, J. and Y. Lotan (2011).
Expert Review of Medical Devices8(1): 97-103.
New technologies such as robotic-assisted surgery are constantly introduced clinically without a complete understanding of benefits and costs. This article will discuss general concepts of health economics and apply them to the application of robotic-assisted surgery to urologic procedures. Utilization of robotic surgery has increased dramatically in recent years. This has been most dramatic in the treatment of prostate cancer. The robot adds significant costs from acquisition, maintenance and recurrent instrument costs. These added costs, thus far, have not been associated with significant improvement in outcomes over ‘pure’ laparoscopy or open procedures. In order for the robot to be cost effective, there needs to be an improvement in efficacy over alternative approaches, and a decrease in costs of the robot or instrumentation. Robotic surgery has not been found to be cost effective in urology. Future studies may yet reveal indirect benefits that are not yet obvious.
“Pilot study of salvage laparoscopic prostatectomy for the treatment of recurrent prostate cancer.”
Ahallal, Y., S. F. Shariat, et al. (2010).
Study Type – Therapy (case series)Level of Evidence 4 OBJECTIVE: To evaluate feasibility, safety and oncological efficacy of salvage laparoscopic radical prostatectomy for pathology-proven biochemical recurrence after primary radiation therapy or cryotherapy for prostate cancer. MATERIALS AND METHODS: This retrospective pilot study examined 15 patients from 2004 to 2010 with biochemical recurrence after external beam radiation therapy (N= 8), brachytherapy (N= 6) or cryotherapy (N= 1). Patients were treated with salvage laparoscopic radical prostatectomy (11 conventional, four robotic-assisted) with bilateral pelvic dissection. RESULTS: Median duration of surgery was 235 min. None of the following occurred: conversion to open surgery, transfusion, urethrovesical stenosis or perioperative or postoperative mortality. One patient presented with a rectal injury, repaired using uninterrupted sutures and a colostomy. One patient had anastomotic leak treated with prolonged Foley catheterization. Pathological stage was pT2a in three, pT2b in three, pT3a in four, pT3b in three and pT4 in two patients; two patients had nodal metastasis. Within an 8-month median follow-up, 11 patients were disease-free and three had persistent postoperative prostate-specific antigen (PSA) elevation; the remaining patient experienced PSA recurrence after 21 months. Seven patients achieved continence (no pads) by 8.4 months (median), one patient manifested severe incontinence corrected by implanting an artificial sphincter, and seven patients with a 12.6-month mean follow-up continued to need one or two pads per day. Erectile dysfunction was present in five patients before surgery and in 14 patients after surgery. CONCLUSIONS: Salvage laparoscopic radical prostatectomy seems to offer a safe therapeutic alternative for patients failing primary radiation or cryotherapy. However, larger studies with longer-term data are required.
“Incidence of bladder neck contracture after robot-assisted laparoscopic and open radical prostatectomy.”
Breyer, B. N., C. B. Davis, et al. (2010).
BJU International106(11): 1734-1738.
OBJECTIVE To evaluate the incidence and risk factors for bladder neck contracture (BNC) in men treated with robot-assisted laparoscopic radical prostatectomy (RALP) and open radical prostatectomy (ORP), as BNC is a well-described complication of ORP and may be partially attributable to technique. PATIENTS AND METHODS The University of California San Francisco Urologic Oncology Database was queried for patients undergoing RALP or ORP from 2002 to 2008. Patient demographics, prostate cancer-specific information, surgical data, and follow-up were collected. For each surgical approach, multivariate Cox proportional hazards regression was performed to evaluate associations of demographics and clinical characteristics with BNC. Time to BNC after RP was evaluated using life table and Kaplan-Meier methods. RESULTS From 2002 to 2008, 988 patients underwent RP as primary treatment and had at least 12 months of follow-up. Of these men, 695 underwent ORP and 293 underwent RALP. The mean (sd) age was 59.3 (6.80) years and 91% of men were Caucasian. D’Amico risk groups at diagnosis were low (38%), intermediate (38%), and high (24%). The BNC incidence was 2.2% (22 cases) overall, 1.4% (four) for RALP, and 2.6% (18) for ORP (P= 0.12). Patients with BNC were diagnosed a median (range) of 4.7 (1-15) months after surgery. At 18 months after surgery, the BNC-free rate was 97% for ORP and 99% for RALP (log-rank P= 0.13). The most common presenting complaint was slow stream, followed by urinary retention. In Cox proportional hazards regression analysis, earlier year of surgery, older age at diagnosis and higher PSA level at diagnosis were significantly associated with BNC among ORP patients. In the RALP group, none of the covariates were associated with BNC. CONCLUSIONS The overall incidence of BNC was low in both RALP and ORP groups. Technical factors such as enhanced magnification and a running bladder anastomosis may explain the lower BNC incidence in the RALP group. © 2010 BJU International.
“Comparison of Oncological Results, Functional Outcomes, and Complications for Transperitoneal Versus Extraperitoneal Robot-Assisted Radical Prostatectomy: A Single Surgeon’s Experience.”
Chung, J. S., W. T. Kim, et al. (2010).
Journal of Endourology.
Abstract Background and Purpose: To compare the oncologic results, functional outcomes, and complications of transperitoneal (TP) and extraperitoneal (EP) robotic radical prostatectomy. Patients and Methods: From June 2007 to April 2009, 105 patients underwent TP robotic radical prostatectomy, and 155 patients underwent EP robotic radical prostatectomy. Clinicopathological and perioperative data were compared between the two groups. Postoperative complications and functional outcomes including potency and incontinence were assessed. Results: Patient demographics were similar in the TP and EP groups. No significant differences in positive surgical margins were noted between the groups. The total operative time, number of lymph nodes removed, and estimated blood loss were also not significantly different. However, the robot console time was shorter for the EP group than for the TP group (89.1 vs. 107.8 minutes, p = 0.03). Postoperative pain scale scores were lower in the EP group than in the TP group (2.7 vs. 6.3, p < 0.001). The incidence of ileus and hernia were lower in the EP group; however, the incidence of lymphocele was higher in the EP group. Postoperative potency and continence rates were similar between the groups; however, the EP group had a faster recovery of continence compared with the TP group. Conclusions: The EP approach has similar oncological and perioperative results, less postoperative pain, less bowel-associated complication, and better functional outcomes than those of the TP approach. The EP approach may be an important alternative in robotic radical prostatectomy.
“A prospective trial comparing consecutive series of open retropubic and robot-assisted laparoscopic radical prostatectomy in a centre with a limited caseload.”
Di Pierro, G. B., P. Baumeister, et al. (2011).
European Urology59(1): 1-6.
Background: Robot-assisted radical prostatectomy (RALP) is performed worldwide, even in institutions with limited caseloads. However, although the results of large RALP series are available, oncologic and functional outcomes as well as complications from low-caseload centres are lacking. Objective: To compare perioperative, oncologic, and functional outcomes from two consecutive series of patients with localised prostate cancer treated by retropubic radical prostatectomy (RRP) or recently established RALP in our hospital, which has a limited caseload. Design, setting, and participants: One hundred fifty consecutive patients were enrolled. Their data and outcomes were collected and extensively evaluated. Intervention: Seventy-five consecutive patients underwent RRP, and 75 consecutive patients underwent RALP, including all patients of the learning curve. Measurements: Patient baseline characteristics, perioperative and postoperative outcomes, and complications were evaluated. End points were oncologic data (positive margins, prostate-specific antigen [PSA]), perioperative complications, urinary continence, and erectile function at 3- and 12-mo follow-up. Results and limitations: The preoperative parameters from the two groups were comparable. The positive surgical margin (PSM) rates were 32% for RRP and 16% for RALP (p = 0.002). For RRP and RALP, the PSA value was <0.2 ng/ml in 91% and 88% of patients 3 mo postoperatively (p = 0.708) and in 87% and 89% of patients 12 mo postoperatively (p = 0.36), respectively. Continence rates for RRP and RALP were 83% and 95% at 3-mo follow-up (p = 0.003) and 80% and 89% after 12-mo follow-up (p = 0.092), respectively. Among patients who were potent without phosphodiesterase type 5 inhibitors (PDE5-I) before RRP and RALP, recovery of erectile function with and without PDE5-Is was achieved in 25% (12 of 49 patients) and 68% (25 of 37 patients) 3 mo postoperatively (p = 0.009) and in 26% (12 of 47 patients) and 55% (12 of 22 patients) 12 mo postoperatively (p = 0.009), respectively. Minimal follow-up for RRP was 12 mo; median follow-up for the RALP group was 12 mo (range: 3-12). According to the modified Clavien system, major complication rates for RRP and RALP were 28% and 7% (p = 0.025), respectively; minor complication rates were 24% and 35% (p = 0.744), respectively. Conclusions: Despite a limited caseload and including the learning curve, RALP offers slightly better results than RRP in terms of PSM, major complications, urinary continence, and erectile function. © 2010 European Association of Urology.
“Oncologic outcome of robot-assisted laparoscopic prostatectomy in the high-risk setting.”
Engel, J. D., W. W. Kao, et al. (2010).
Journal of Endourology24(12): 1963-1966.
Background and Purpose: Previous studies have demonstrated the feasibility of open radical prostatectomy in the high-risk setting. Management of high-risk disease with robot-assisted laparoscopic radical prostatectomy (RALP) is controversial. We examined biochemical recurrence in a selected cohort of high-risk patients who were undergoing RALP. Patients and Methods: Men with high-risk prostate cancer who underwent bilateral nerve-sparing, nonsalvage RALP by a single surgeon without adjuvant or neoadjuvant therapy of any kind were identified. High risk was defined by preoperative prostate-specific antigen (PSA) level >10ng/dL, Gleason score ≥8 on final pathologic evaluation, or stage ≥pT<sub>3</sub>. Postoperative PSA value ≥0.2ng/dL defined biochemical recurrence. Results: A total of 73 men were identified. There was no significant difference in surgical margin positivity (38% overall) or prostate size between recurrence and nonrecurrence cohorts. Biochemical failure was significantly associated with higher pathologic Gleason score (P=0.0085) but not pathologic stage (P=0.22) or preoperative PSA level (P=0.18). With follow-up to 85 months (mean 31.8 mos), biochemical recurrence-free survival was 77% with mean time to recurrence of 7.7 months. Recurrence occurred significantly earlier than later (P<0.001). Conclusions: Reasonable short-to intermediate-term biochemical outcomes can be achieved in a recurrence-prone group of high-risk men who are undergoing RALP. RALP is feasible in a selected cohort of high-risk men who are undergoing aggressive local therapy. Copyright © 2010, Mary Ann Liebert, Inc.
“Surgery illustrated – Focus on details: Early release of pedicles and posterior development of the “veil of Aphrodite” in robotic-assisted laparoscopic prostatectomy (RALP).”
Ischia, J., S. Sengupta, et al. (2010).
BJU International106(11): 1856-1861.
“The Impact of Anterior Urethropexy During Robotic Prostatectomy on Urinary and Sexual Outcomes.”
Johnson, E. K., R. C. Hedgepeth, et al. (2010).
Journal of Endourology.
Abstract Objectives: We determined the effect of an anterior urethropexy (AU) stitch on postoperative urinary continence, irritative urinary symptoms, and sexual function after robotic radical prostatectomy (RP). Methods: Consecutive patients undergoing robotic RP for prostate cancer were prospectively evaluated. The Expanded Prostate Cancer Index Composite (EPIC) questionnaire was administered pre- and postoperatively to all patients. Patients were then grouped by AU status. A linear mixed model was used to compare the rate of recovery in incontinence (UIN), irritative (UIR), and sexual domain scores between the two groups. A t-test was used to compare UIN, UIR, and sexual domain scores at specific time points. Results: A total of 229 patients underwent robotic RP and filled out a preoperative and at least one postoperative EPIC questionnaire. In this population, 87 did have and 142 did not have an AU performed. The mean EPIC-UIN score at 3 months was 68 in the AU group and 58 in the non-AU group (p = 0.015). Comparison of all other time points and overall urinary scores revealed no other statistically significant differences after surgery. Sexual domain scores were also improved at 3 months in the AU group (p = 0.002). Conclusions: AU during robotic RP leads to improved urinary continence and sexual functioning at 3 months of follow-up. An earlier return to continence may facilitate an earlier return to sexual activity. AU may offer a short-term quality-of-life advantage for patients undergoing robotic RP.
“Avoiding and dealing with the complications of robot-assisted laparoscopic radical prostatectomy.”
Kirby, R., K. Patil, et al. (2010).
BJU International106(11): 1567-1569.
“Robot-assisted radical prostatectomy: Is the dust settling?”
Menon, M. (2011).
European Urology59(1): 7-9.
“A technique for the management of a large median lobe in robot-assisted laparoscopic radical prostatectomy.”
Patel, S. R., D. M. Kaplon, et al. (2010).
Journal of Endourology24(12): 1899-1901.
An enlarged median lobe is encountered 8% to 18% of the time during robot-assisted laparoscopic prostatectomy. A large intravesical lobe can obscure the anatomy of the bladder neck and generate a large bladder neck, necessitating reconstruction. In addition, it may increase the likelihood of ureteral injury, positive surgical margin, and residual prostate tissue. When encountering this anatomic variant, a clear surgical plan is required. We describe our approach to the large median lobe and highlight a specific technique that may be beneficial in managing this anatomic variant. Copyright © 2010, Mary Ann Liebert, Inc.
“Comparative effectiveness of perineal versus retropubic and minimally invasive radical prostatectomy.”
Prasad, S. M., X. Gu, et al. (2011).
Journal of Urology185(1): 111-115.
Purpose While perineal radical prostatectomy has been largely supplanted by retropubic and minimally invasive radical prostatectomy, it was the predominant surgical approach for prostate cancer for many years. In our population based study we compared the use and outcomes of perineal radical prostatectomy vs retropubic and minimally invasive radical prostatectomy. Materials and Methods We identified men diagnosed with prostate cancer from 2003 to 2005 who underwent perineal (452), minimally invasive (1,938) and retropubic (6,899) radical prostatectomy using Surveillance, Epidemiology and End Results-Medicare linked data through 2007. We compared postoperative 30-day and anastomotic stricture complications, incontinence and erectile dysfunction, and cancer therapy (hormonal therapy and/or radiotherapy). Results Perineal radical prostatectomy comprised 4.9% of radical prostatectomies during our study period and use decreased with time. On propensity score adjusted analysis men who underwent perineal vs retropubic radical prostatectomy had shorter hospitalization (median 2 vs 3 days, p <0.001), received fewer heterologous transfusions (7.2% vs 20.8%, p <0.001) and required less additional cancer therapy (4.9% vs 6.9%, p = 0.020). When comparing perineal vs minimally invasive radical prostatectomy men who underwent the former required more heterologous transfusions (7.2% vs 2.7%, p = 0.018) but experienced fewer miscellaneous medical complications (5.3% vs 10.0%, p = 0.045) and erectile dysfunction procedures (1.4 vs 2.3/100 person-years, p = 0.008). The mean and median expenditure for perineal radical prostatectomy in the first 6 months postoperatively was $1,500 less than for retropubic or minimally invasive radical prostatectomy (p <0.001). Conclusions Men who undergo perineal vs retropubic and minimally invasive radical prostatectomy experienced favorable outcomes associated with lower expenditure. Urologists may be abandoning an underused but cost-effective surgical approach that compares favorably with its successors. © 2011 American Urological Association Education and Research, Inc.
“Benign prostatic hyperplasia and prostate cancer: An overview for primary care physicians.”
Sausville, J. and M. Naslund (2010).
International Journal of Clinical Practice64(13): 1740-1745.
Benign prostatic hyperplasia (BPH) and prostate cancer (CaP) are major sources of morbidity in older men. Management of these disorders has evolved considerably in recent years. This article provides a focused overview of BPH and CaP management aimed at primary care physicians. Current literature pertaining to BPH and CaP is reviewed and discussed. The management of BPH has been influenced by the adoption of effective medical therapies; nonetheless, surgical intervention remains a valid option for many men. This can be accomplished with well-established standards such as transurethral resection of the prostate or with minimally invasive techniques. Prostate cancer screening remains controversial despite the recent publication of two large clinical trials. Not all prostate cancers necessarily need to be treated. Robot-assisted prostatectomy is a new and increasingly utilised technique for CaP management, although open radical retropubic prostatectomy is the oncological reference standard. The ageing of the population of the developed world means that primary care physicians will see an increasing number of men with BPH and CaP. Close collaboration between primary care physicians and urologists offers the key to successful management of these disorders. © 2010 Blackwell Publishing Ltd.
“First 500 cases of robotic-assisted laparoscopic radical prostatectomy from a single UK centre: learning curves of two surgeons.”
Sharma, N. L., A. Papadopoulos, et al. (2010).
Study Type – Therapy (case series)Level of Evidence 4 OBJECTIVE: To study the outcomes and learning curve of robotic-assisted laparoscopic radical prostatectomy (RALP) in a single centre by two surgeons. PATIENTS AND METHODS: In total, 500 consecutive patients underwent RALP between 2005 and 2009 carried out by two surgeons. Using an ethically-approved database, prospective data collection of demographic, surgical, oncological and functional outcomes (patient reported) was performed, with up to 4 years of follow-up. The learning curves of both surgeons were analyzed and, in addition, the first 100 and last 100 patients were compared to determine the effect of surgeon experience. RESULTS: The mean age of the patients was 61.5 years and mean preoperative prostate-specific antigen was 7.0 microg/L. Clinical stages were T1 in 63.2%, T2 in 33.8% and T3 in 3.0% of patients. Median (range) operating time was 170 (63-420) min and median (range) blood loss was 200 (20-3000) mL, with significant improvements for both surgeons with increasing experience (P < 0.001 and P= 0.029, respectively). Pathological stages were pT2 in 53.4%, pT3a in 41.6%, pT3b in 4.0% and pT4 in 0.6% of patients. Overall, the positive margin rate (PMR) was 24.0% and stage-specific rates were 16.1%, 30.4%, 55.0% and 100.0% for pT2, pT3a, pT3b and pT4 disease, respectively. In the last 50 cases performed by each surgeon, the PMRs for pT2 and pT3a disease were 8.0% and 19.1% (surgeon 1) and 12.9% and 23.5% (surgeon 2). At 12 months of follow-up, 91.3% of patients were continent and, by 48 months of follow-up, 75% of men with preoperative potency who underwent bilateral nerve-sparing RALP were potent. CONCLUSIONS: This is the first report of two surgeons’ learning curves in a single centre and shows that key learning curve outcomes continued to improve during the series, suggesting that the learning curve for RALP may be longer than has been previously suggested.
“Robot-assisted laparoscopic radical prostatectomy in men with human immunodeficiency virus.”
Silberstein, J. L., J. K. Parsons, et al. (2010).
Prostate Cancer and Prostatic Diseases13(4): 328-332.
The aim of this study is to evaluate the outcomes of robot-assisted laparoscopic prostatectomy (RALP) in prostate cancer (PCa) patients with human immunodeficiency virus (HIV). This is a prospective cohort study of HIV patients undergoing RALP, comparing the demographics, tumor characteristics, complications, and short-term oncological outcomes of HIV-positive men to HIV-negative men using univariate (χ<sup>2</sup>, Mann-Whitney test) and multivariable (logistic regression) analyses. From 2007 to 2010, 298 men underwent RALP, 8 of whom were known to be HIV positive. Preoperatively, all eight were taking highly active antiretroviral therapy (HAART) and had undetectable viral loads (<50); mean CD4 count was 634 cells per mm 3. HIV-positive men were younger (54 versus 62 years, P=0.010) and less likely to be white (P=0.007). There were no significant differences between groups with respect to clinical staging, pathological and oncological outcomes or most complication rates. However, the prevalence of perioperative transfusions (P=0.031) and ileus (P=0.021) were higher in HIV-positive patients. HIV remained significantly associated with risk of transfusion after adjustment for age, race, Gleason sum and clinical T stage (P=0.002). After a median of 2.6 (range 0.03-19.2) months of follow-up, PSA remained undetectable in all eight HIV patients. These data suggest that RALP is safe for, and demonstrates short-term oncological efficacy in, HIV-positive patients with PCa. © 2010 Macmillan Publishers Limited All rights reserved.
“LAPPRO: A prospective multicentre comparative study of robot-assisted laparoscopic and retropubic radical prostatectomy for prostate cancer.”
Thorsteinsdottir, T., J. Stranne, et al. (2010).
Scandinavian Journal of Urology and Nephrology.
Abstract Objective. This study describes the study design and procedures for a prospective, non-randomized trial comparing open retropubic and robot-assisted laparoscopic radical prostatectomy regarding functional and oncological outcomes. Material and methods. The aim was to achieve a detailed prospective registration of symptoms experienced by patients using validated questionnaires in addition to documentation of surgical details, clinical examinations, medical facts and resource use. Four patient questionnaires and six case-report forms were especially designed to collect data before, during and after surgery with a follow-up time of 2 years. The primary endpoint is urinary leakage 1 year after surgery. Secondary endpoints include erectile dysfunction, oncological outcome, quality of life and cost-effectiveness at 3, 12 and 24 months after surgery. Results. The study started in September 2008 with accrual continuing to October 2011. Twelve urological departments in Sweden well established in performing radical prostatectomy are participating. Personal contact with the participating departments and patients was established to ascertain a high response rate. To reach 80% statistical power to detect a difference of 5 absolute per cent in incidence of urinary leakage, 700 men in the retropubic group and 1400 in the robotic group are needed. Conclusions. The Swedish healthcare context is well suited to performing multicentre long-term prospective clinical trials. The similar care protocols and congruent specialist training are particularly favourable. The LAPPRO trial aims to compare the two surgical techniques in aspects of short- and long-term functional and oncological outcome, cost effectiveness and quality of life, supplying new knowledge to support future decisions in treatment strategies for prostate cancer.
“Primary left upper quadrant (Palmer’s point) access for laparoscopic radical prostatectomy.”
Tüfek, I., H. Akpinar, et al. (2010).
Urology Journal7(3): 152-156.
Purpose: Although Palmer’s point approach is described for upper urinary tract laparoscopy, we use this technique routinely for robotic and standard laparoscopic radical prostatectomy and we describe our experience with this approach. Materials and Methods: Since 2004, Palmer’s point Veress entry has been used to create pneumoperitoneum in 126 robotic and 21 standard laparoscopic radical prostatectomies. On the left side, a 2-mm transverse skin incision was made 3 cm below the left costal margin on the midclavicular line. Through this incision, a Veress needle was inserted to create pneumoperitoneum. Results: The mean patients’ age and body mass index were 59.7 years (range, 37 to 73 years) and 27.92 kg/m<sup>2</sup> (range, 22 to 39 kg/m<sup>2</sup>), respectively. Thirty-eight patients had prior abdominal operations. The mean number of punctures performed was 1.08 per case. In 93 % of the subjects, Veress needle was inserted during the first attempt. The mean time to establish pneumoperitoneum was 5.63 minutes (range, 4 to 8 minutes). No major entrance injuries occurred. Conclusion: Palmer’s point upper quadrant Veress needle access may be a safe and effective method of establishing pneumoperitoneum in patients subjected to robotic and standard laparoscopic radical prostatectomy.
“Early oncological outcomes of robot-assisted radical prostatectomy for high-grade prostate cancer.” Wambi, C. O., S. A. Siddiqui, et al. (2010).
BJU International106(11): 1739-1745.
OBJECTIVE To evaluate the oncological outcomes of patients with specimen Gleason 8 and 9 prostate cancers and to determine factors that predict biochemical recurrence-free survival (BCRFS) after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS Of 4156 patients who underwent RARP from January 2001 to 2009, we identified 368 men with Gleason 8 or 9 tumours who met the inclusion criteria. BCR was defined as a PSA level of ≥0.2 ng/mL with a second rising value. The Kaplan-Meier method and log-rank test were used to compare BCRFS while factors that predict BCRFS were determined by Cox proportional hazards modelling. RESULTS The median age and PSA level were 62 years and 6.4 ng/mL for men with Gleason 8, and 63 years and 6.7 ng/mL for Gleason 9 cancers. The median (interquartile range, IQR) overall follow-up was 23 (10-46) months and 19 (7-37) months for Gleason 8 and 9 tumours, respectively. At 60 months the mean (se) overall BCRFS was 36 (5)% and for Gleason 8 it was 47 (6)% and for Gleason 9 it was 21 (7)% (P < 0.001). At 5 years, extraprostatic extension (pT3a) resulted in BCRFS of 52 (9)% for Gleason 8 tumours and 21 (11)% for Gleason 9 (P= 0.012). On multivariable analysis, lymph node invasion, specimen Gleason score, pathological stage and tumour volume predicted BCRFS. CONCLUSIONS Early results suggest RARP monotherapy performs comparably to RP for BCRFS in men with high-grade prostate cancer. There are significant oncological differences between Gleason 8 and 9 tumours. © 2010 HENRY FORD HOSPITAL HEALTH SYSTEM.
“Application of ice cold irrigation during vascular pedicle control of robot-assisted radical prostatectomy: EnSeal instrument cooling to reduce collateral thermal tissue damage.”
Zorn, K. C., N. Bhojani, et al. (2010).
Journal of Endourology24(12): 1991-1996.
Background and Purpose: Energy-based hemostasis of the prostatic vascular pedicles (PVP) during robot-assisted radical prostatectomy (RARP) may cause collateral thermal injury to adjacent neural tissue and has been shown to negatively impact sexual function recovery. The unique engineering design of the EnSeal<sup>®</sup> (Ethicon, Cincinnati, OH) has been demonstrated to limit collateral thermal tissue damage to <1.0mm. Use of tissue and instrument cooling before and during device activation may potentially further reduce thermal spread. As such, we sought to evaluate the collateral tissue effects of EnSeal with or without cold saline irrigation (CSI) during PVP control. Patients and Methods: The EnSeal Trio device was used for PVP control in 20 consecutive men undergoing bilateral, non-nerve-sparing RARP. Ipsilateral vascular pedicles were randomly selected to EnSeal plus CSI (<4°C) application to the tissue before and during device activation or EnSeal alone. The primary end point was the distance of thermal injury from the inked margin using both hematoxylin and eosin (H&E) and terminal transferase uridyl nick end-labeling (TUNEL) apoptosis staining. A mean of three measurements was taken for each pedicle. Pathologic analysis was performed by a single, blinded uropathologist. Results: Mean distance of thermal injury from the inked margin using H&E staining was 0.31mm (range 0.15-0.40mm) and 0.98mm (range 0.7-1.2mm) for the EnSeal plus CSI and EnSeal alone, respectively (P<0.0001). TUNEL staining also demonstrated lateral tissue damage of 0.39mm (range 0.2-0.5mm) and 1.12mm (range 0.9-1.3mm), respectively (P<0.001). No complications related to hemostasis or postoperative bleeding were observed in the study. Conclusions: The hemostatic properties of EnSeal work effectively when submerged in CSI. Adjacent thermal tissue damage is significantly minimized with the addition of CSI. This may have a beneficial impact on nerve preservation and sexual function outcomes after RARP. Copyright © 2010, Mary Ann Liebert, Inc.