Abstrakt Urologie Srpen 2010

“Robot-assisted Tapered Ureteral Reimplantation for Congenital Megaureter.”

Goh, A. C. and R. E. Link (2010).



OBJECTIVE: To discuss the clinical implications of primary obstructed congenital megaureter in the adult and illustrate a minimally-invasive approach for surgical intervention. METHODS: We present the case of a 51-year-old man with a longstanding history of symptomatic congenital megaureter, illustrating an approach for robot-assisted tapered ureteral reimplantation. Ureteral dissection, tapering, and nonrefluxing ureteroneocystostomy were all completed using a robot-assisted laparoscopic technique. RESULTS: The total operative time was 262 minutes, with an estimated blood loss of 150 mL. The patient’s hospital course was uneventful, with discharge on postoperative day 4 without a Foley catheter or drain. A diuretic renal scan was performed at 5 months that showed good preservation of renal function with rapid clearance of tracer on the reconstructed side. The patient was pain free at his last follow-up visit without any symptoms. CONCLUSIONS: We have demonstrated a technique for robot-assisted tapered nonrefluxing ureteral reimplantation for congenital megaureter. Robotic assistance provided a safe and effective approach for complex ureteral reconstruction while minimizing morbidity.




“Robot-assisted laparoscopic intracorporeal hand-sewn bowel anastomosis during pediatric bladder reconstructive surgery<sup>*</sup>.”

Gundeti, M. S., A. L. Wiltz, et al. (2010).

Journal of Endourology 24(8): 1325-1328.


Bowel anastomosis performed during robot-assisted laparoscopic surgery in both adult and pediatric populations has typically been performed using endoscopic staplers or with exteriorization of the bowel. In the pediatric population, no articles have been published that explore the possibility of a completely intracorporeal hand-sewn anastomosis during robot-assisted laparoscopic surgery. We report our series of six children who were undergoing robot-assisted laparoscopic intracorporeal hand-sewn bowel anastomosis during bladder reconstructive surgery for neurogenic bladder. The postoperative course was uncomplicated with regard to the bowel anastomosis, demonstrating the feasibility of the technique in experienced hands. © Copyright 2010, Mary Ann Liebert, Inc.




“Reply from Authors re: Urs E. Studer, Laurence Collette. Robot-assisted cystectomy: Does it meet expectations? Eur Urol 2010;58:203-4.”

Hayn, M. H., A. Hussain, et al. (2010).

European Urology 58(2): 204-206.




“Experience with robotic assisted laparoscopic surgery in upper tract urolithiasis.”

Hemal, A. K., R. Nayyar, et al. (2010).

Can J Urol 17(4): 5299-5305.


OBJECTIVE: Early results indicate that robot assisted laparoscopic surgery (RALS) may be useful in managing upper tract (UT) urolithiasis. We reviewed our experience of managing 50 cases of UT urolithiasis with or without reconstruction using RALS. MATERIALS AND METHODS: We performed a record review of 50 cases of RALS for UT urolithiasis performed in two institutions from July 2006 to June 2009. The RALS procedures included pyeloplasty with pyelolithotomy (29 cases), ureterolithotomy, tailoring and reimplantation for megaureters (5 cases), ureterolithotomy with ureteral stricture reconstruction (1 case), primary UT stone surgeries (8 cases), partial nephrectomy (1 case) and ablative surgeries (6 cases). Data pertaining to indications, operative details, and complications were analyzed. RESULTS: The average operating time was 105 min (86 min-135 min) for pyeloplasty with pyelolithotomy, 140 min (115 min-195 min) for ureterolithotomy, tailoring and ureteroneocystostomy and 106 min (88 min-174 min) for extended pyelolithotomy (5 cases). Mean blood loss was 77 mL (50 mL-250 mL). Stone clearance rate was 93.2%. One case of extended pyelolithotomy had hematuria requiring selective angioembolization. There was one conversion and no other major complication. CONCLUSIONS: RALS for UT urolithiasis is safe and efficacious. It is particularly useful when stone removal is combined with reconstruction. It is a reasonable alternative for treating a solitary partial staghorn or a large pelvic stone including those in pelvic/anomalous kidneys. RALS did not seem substantially better than pure laparoscopy for isolated ureterolithotomy and for nephrectomy for a nonfunctioning kidney. Its role in the treatment of large, multiple or complete staghorn calculi needs further investigation.




“Robotic-assisted Radical Cystectomy and Orthotopic Ileal Neobladder Using a Modified Pfannenstiel Incision.”

Manoharan, M., D. Katkoori, et al. (2010).



OBJECTIVES: To report our technique of robotic-assisted laparoscopic radical cystectomy with a modified Pfannenstiel incision. Robotic-assisted laparoscopic radical cystectomy has been gaining in popularity. A completely intracorporeal procedure is a technically difficult and time-consuming procedure. Most surgeons perform the diversion using a small incision, typically midline, that is also used for specimen retrieval. METHODS: Radical cystectomy and pelvic lymph node dissection was performed using a da Vinci robotic platform in a standard fashion. The robot was undocked and an 8-10 cm modified Pfannenstiel incision made. A self-retaining retractor was used to expose the wound. The specimen was extracted, and an ileal neobladder was reconstructed using the incision. RESULTS: We have performed this procedure in 14 patients to date. The mean age was 58 years (range 56-61). The mean estimated blood loss was 310 +/- 220 mL, and the mean operating time was 6 +/- 0.8 hours. No intraoperative visceral injuries were noted. None of the patients had positive surgical margins. The mean number of lymph nodes removed was 12 +/- 3. The mean hospital stay was 8.5 days. CONCLUSIONS: Our initial experience with our technique of robotic-assisted laparoscopic radical cystectomy and neobladder construction using a modified Pfannenstiel incision has been favorable. The incision provides good exposure, facilitating neobladder reconstruction, can be used for specimen retrieval, and heals better with a cosmetic scar.




“Robot-assisted cystectomy: Does it meet expectations?”

Studer, U. E. and L. Collette (2010).

European Urology 58(2): 203-204.




“Retroperitoneal and Transperitoneal Robot-Assisted Pyeloplasty in Adults: Techniques and Results.”

Cestari, A., N. M. Buffi, et al. (2010).

European Urology.


BACKGROUND: The surgical management of ureteropelvic junction obstruction (UPJO) has dramatically evolved over the past 20 yr due to the development of new technology. OBJECTIVE: Our aim was to report the feasibility and efficacy of robot-assisted pyeloplasty (RAP) performed by either the retroperitoneal or the transperitoneal approach. DESIGN, SETTING, AND PARTICIPANTS: A stage 2 investigative study was conducted including development (stage 2a) and exploration (stage 2b) of transperitoneal and retroperitoneal RAP performed in 55 patients at an urban tertiary university department of urology. SURGICAL PROCEDURE: Retroperitoneal RAP was performed with the patient in full flank position using a 12-mm Hasson-style optical port at the tip of the 12th rib, plus two operative 8-mm robotic trocars and an assistant 5-mm port. The stenotic ureteropelvic junction was excised, the ureter was spatulated, and a dismembered pyeloplasty was performed in all cases. Transperitoneal RAP was performed with the patients in the 60 degrees flank position. The optical port is in the umbilical area, plus two 8-mm operative robotic ports and one 5-mm assistant port. The pyeloplasty technique is similar to the retroperitoneoscopic approach. In both groups, the stent can be positioned in an anterograde or retrograde fashion. MEASUREMENTS: Success consisted of no evidence of obstruction on computed tomography urography or mercaptoacetyltriglycine-3 diuretic renal scan, no postoperative symptoms, and no further treatment. RESULTS AND LIMITATIONS: Thirty-six patients underwent retroperitoneoscopic RAP and 19 transperitoneal RAP for UPJO. All the procedures were completed with robotic assistance. The overall objective success (measured by diuretic renal scan and/or imaging techniques) was 96% with two cases of recurrence (both in the retroperitoneal group). The main limitation was the short follow-up, although all patients reached at least a 6-mo follow-up. CONCLUSIONS: RAP performed either retroperitoneally or transperitoneally was revealed as a feasible and reproducible surgical option for the treatment of UPJO, offering a subjective optimal plasty reconfiguration at short follow-up.




“Robot-Assisted Pyeloplasty: Follow-Up of First Canadian Experience with Comparison of Outcomes Between Experienced and Trainee Surgeons.”

Erdeljan, P., Y. Caumartin, et al. (2010).

Journal of Endourology.


Abstract Background and Purpose: Robot-assisted pyeloplasty (RAP) has been established recently as an option in the management of ureteropelvic junction obstruction (UPJO). We present the first Canadian experience with RAP with respect to operative results and outcomes. We compare the surgical outcomes between experienced and trainee surgeons, with respect to operating room times and success rates. Patients and Methods: Eighty-eight patients underwent transperitoneal RAP for UPJO using the da Vinci robotic platform. Two surgeons performed Anderson-Hynes dismembered pyeloplasty in 85 cases and YV-plasty in 5 cases. Five patients had RAP for secondary UPJO after failure of other treatments. Diuretic renography was performed at 6 weeks, and 6, 12, 18, 24, and 36 months postpyeloplasty. The mean follow-up was 14.1 +/- 8.5 months. Results: The mean operative time was 167.7 +/- 43.2 minutes, and the mean anastomotic time was 41.9 +/- 14.1 minutes. The mean operative duration significantly decreased with time (P < 0.05). Ten patients needed simultaneous nephroscopic stone management via the pyelotomy incision. The mean blood loss was 56.6 +/- 55.4 mL, and the mean hospital stay was 2.5 +/- 0.5 days. There were five major postoperative (stent migration, urinoma) and three minor complications that were associated with the RAP procedures. Postoperative renal scintigraphy demonstrated only four cases with persistent obstruction. Eighty-three (94.3%) patients experienced improvement of symptoms whereas 5 continued to be symptomatic. Two patients needed secondary procedures to relieve persisting obstruction. There were no statistical differences in outcomes between the experienced surgeons and trainees (P = 0.28). Conclusions: In the first large case series of RAP from Canada, we demonstrate that RAP can be performed with relatively short operative times and is safe and effective, achieving similar long-term results with standard open repair. We show that robot-assisted surgery can be safely transitioned to surgical trainees. With its cost and availability, its role in the Canadian system needs further study.




“Warm ischaemia: The ultimate enemy for partial nephrectomy?”

Pignot, G., F. Boulire, et al. (2010).

European Urology 58(3): 337-339.




“Metanephric adenofibroma: robotic partial nephrectomy of a large Wilms’ tumor variant.”

Piotrowski, Z., D. J. Canter, et al. (2010).

Can J Urol 17(4): 5309-5312.


PURPOSE: A case of the rare, benign, Wilms’ tumor (WT) variant, metanephric adenofibroma (MAF), is presented. MATERIALS AND METHODS: The patient is a 21-year-old female with an incidentally discovered enhancing renal mass. The diagnosis, workup and treatment are outlined. RESULTS: The 19 cm renal mass was ultimately resected via robot-assisted partial nephrectomy. Pathologic diagnosis at our institution was confirmed as a MAF by the National Wilms’ Tumor Study Group (NWTSG). CONCLUSION: Difficult to differentiate from WT, it is imperative that MAF be recognized and appropriately diagnosed because unlike adult WT, the natural history of MAF is indolent and adjuvant chemo/radiation therapy is rarely necessary. This case reinforces the importance of review of potential WT variants by the NWTSG.




“Complete periprostatic anatomy preservation during Robot-Assisted Laparoscopic Radical Prostatectomy (RALP): The new pubovesical complex-sparing technique.”

Asimakopoulos, A. D., F. Annino, et al. (2010).

European Urology 58(3): 407-417.


Background: Puboprostatic ligament preservation has been proposed as a method to accelerate continence recovery after radical prostatectomy (RP). However, these ligaments present anatomic continuity with the bladder, and there must be interruption at some point to expose the prostatourethral junction. Objectives: To describe the surgical steps of pubovesical complex (PVC)-sparing robot-assisted laparoscopic RP (RALP) and present the preliminary results of our technique. Design, setting, and participants: Thirty PVC-sparing RALP procedures were performed in patients <60 yr with clinically localised prostate cancer between 2007 and 2009 by the same surgeon. Surgical procedure: The principles of bladder neck preservation, tension and energy-free dissection of the bundles as well as seminal vesicle sparing are applied. Ventrally, a plane of dissection is developed between the detrusor apron and the prostate. The soft connective tissue between Santorini’s plexus and the prostate is blandly dissected, leaving the plexus intact and in place. Measurements: The rates and location of positive surgical margins (PSM) as well as functional outcomes are presented. Results and limitations: Three of 30 patients (10%) had a PSM (two apical margins and one on the left posterolateral side). At catheter removal, 24 of 30 patients (80%) were dry (0 pads), and 6 of 30 patients (20%) needed one security pad. After 3 mo, 22 of 30 patients (73%) presented an International Index of Erectile Function score >17 (with or without phosphodiesterase type 5 inhibitors). Thirteen of 22 potent patients had an Erection Hardness Score of 3, and 9 of 22 patients had a score of 4. Small sample size, low mean age of enrolled patients (52 yr), and the absence of diseases that could impair the continence and potency recovery are some of the limitations of the study. Moreover, it is difficult to quantify the effect of each applied continence-sparing technique. Conclusions: The holistic preservation of the PVC during RALP is technically feasible. It leads towards an absolute preservation of the periprostatic anatomy that may enhance early functional outcomes. Further studies are needed to confirm our results. © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.




“Impact of body mass index on perioperative outcomes during the learning curve for robot-assisted radical prostatectomy.”

Chalasani, V., C. H. Martinez, et al. (2010).

Canadian Urological Association Journal 4(4): 250-254.


INTRODUCTION: Previous studies of robotic-assisted radical prostatectomy (RARP) have suggested that obesity is a risk factor for worse perioperative outcomes. We evaluated whether body mass index (BMI) adversely affected perioperative outcomes. METHODS: A prospective database of 153 RARP (single surgeon) was analyzed. Obesity was defined as BMI >/= 30 kg/m(2); normal BMI < 25 kg/m(2); and overweight as 25 to 30 kg/m(2). Two separate analyses were performed: the first 50 cases (the initial learning curve) and the entire cohort of 153 RARP. RESULTS: In the initial cohort of 50 cases (14 obese patients), there was no statistically significant difference with regards to operative times, port-placement times and estimated blood loss (EBL). Length of stay (LOS) was longer in the obese group (4.3 vs. 2.9 days); BMI remained an independent predictor of increased LOS on multivariate linear regression analysis (p = 0.002). There was no statistically significant difference in the postoperative outcomes of leak rates, margin rates and incisional herniae. In the entire cohort, when comparing obese patients to those with a normal BMI, there was no statistically significant difference in operative times, EBL, LOS, or immediate postoperative outcomes. However, on multivariate linear regression analysis, BMI was an independent predictor of increased operative time (p = 0.007). CONCLUSION: Obese patients do not have an increased risk of blood loss, positive margins or the postoperative complications of incisional hernia and leak during the learning curve. They do, however, have slightly longer operative times; we also noted an increased LOS in our first 50 cases.




“Comparative risk-adjusted mortality outcomes after primary surgery, radiotherapy, or androgen-deprivation therapy for localized prostate cancer.”

Cooperberg, M. R., A. J. Vickers, et al. (2010).



BACKGROUND:: Because no adequate randomized trials have compared active treatment modalities for localized prostate cancer, the authors analyzed risk-adjusted, cancer-specific mortality outcomes among men who underwent radical prostatectomy, men who received external-beam radiation therapy, and men who received primary androgen-deprivation therapy. METHODS:: The Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry comprises men from 40 urologic practice sites who are followed prospectively under uniform protocols, regardless of treatment. In the current study, 7538 men with localized disease were analyzed. Prostate cancer risk was assessed using the Kattan preoperative nomogram and the Cancer of the Prostate Risk Assessment (CAPRA) score, both well validated instruments that are calculated from clinical data at the time of diagnosis. A parametric survival model was constructed to compare outcomes across treatments adjusting for risk and age. RESULTS:: In total, 266 men died of prostate cancer during follow-up. Adjusting for age and risk, the hazard ratio for cancer-specific mortality relative to prostatectomy was 2.21 (95% confidence interval [CI], 1.50-3.24) for radiation therapy and 3.22 (95% CI, 2.16-4.81) for androgen deprivation. Absolute differences between prostatectomy and radiation therapy were small for men at low risk but increased substantially for men at intermediate and high risk. These results were robust to a variety of different analytic techniques, including competing risks regression analysis, adjustment by CAPRA score rather than Kattan score, and examination of overall survival as the endpoint. CONCLUSIONS:: Prostatectomy for localized prostate cancer was associated with a significant and substantial reduction in mortality relative to radiation therapy and androgen-deprivation monotherapy. Although this was not a randomized study, given the multiple adjustments and sensitivity analyses, it is unlikely that unmeasured confounding would account for the large observed differences in survival. Cancer 2010. (c) 2010 American Cancer Society.




“A cohort study investigating patient expectations and satisfaction outcomes in men undergoing robotic assisted radical prostatectomy.”

Douaihy, Y. E., P. Sooriakumaran, et al. (2010).

International Urology and Nephrology.


INTRODUCTION: Robotic assisted radical prostatectomy (RARP) is gaining widespread acceptance for the management of localized prostate cancer. However, data regarding patient expectations and satisfaction outcomes after RARP are scarce. METHODS: We developed a structured program for preoperative education and evidence-based counseling using a multi-disciplinary team approach and measured its impact on patient satisfaction in a cohort of 377 consecutive patients who underwent RARP at our institution. Responses regarding overall, sexual, and continence satisfaction were assessed. RESULTS: Fifty percent of our patient cohort replied to the questionnaire assessments. Ninety-three percent of responding patients expressed overall satisfaction after RARP with only 0.5% expressing regret at having had the operation. Biochemical recurrence and lack of continence correlated significantly with low levels of satisfaction, though sexual function was not significantly different among those satisfied and those not. Most patients (97%) valued oncologic outcome as their top priority, with regaining of urinary control being the commonest second priority (60%). CONCLUSIONS: RARP appears to be associated with a high degree of patient satisfaction in a cohort of patients subjected to a structured preoperative education and counseling program. Oncologic outcomes are most important to these patients and have the largest influence on satisfaction scores.




“Impact of regional hypothermia on urinary continence and potency after robot-assisted radical prostatectomy.”

Finley, D. S., A. Chang, et al. (2010).

Journal of Endourology 24(7): 1111-1116.


Background and Purpose: This is the third publication that updates clinical outcomes using a novel technique to apply locoregional hypothermia to the pelvis during robot-assisted radical prostatectomy (RARP) to reduce inflammatory injury. This report updates urinary and sexual clinical outcomes with a minimum of 1 year follow-up. Patients and Methods: Regional pelvic cooling (<300°C) was achieved with a prototype endorectal cooling balloon (ECB) during the course of RARP. All clinical data were entered prospectively into an electronic database for historic (cases 1-666) and hypothermic groups (115? pts). Urinary and sexual outcomes were obtained using self-administered validated questionnaires. Continence was defined as no pads, and potency was defined as two affirmative answers to “erections adequate for penetration” and “were the erections satisfactory.” Results: Six patients were excluded: three ECB malfunction, three previous radiation/surgery. Median time to zero pad use was 39 days vs 62 days (hypothermic vs controls, P? =? 0.0003). At 1 year, overall pad-free continence was 96.3% (105/109) vs controls of 86.6%, P? <? 0.001. Potency was evaluated in all men (40-78 years) with preoperative International Index of Erectile Function-5 scores of 22 to 25. At 3 months, potency results were unchanged between groups: 24% vs 23%. At 15 months, the potency rates were significantly better for the hypothermic group, 83% vs controls 66%, P? =? 0.045. No difference in oncologic outcome was noted with cooling. Conclusions: Using a prototype cooling balloon, hypothermic RARP significantly improved time to continence and overall continence. Hypothermia also resulted in a modest but statistically significant improvement in potency at 15 months. Once cooling parameters have been optimized, a randomized multicenter clinical trial will be needed for validation. © 2010, Mary Ann Liebert, Inc.




“A new anatomic approach for robot-assisted laparoscopic prostatectomy: A feasibility study for completely intrafascial surgery.”

Galfano, A., A. Ascione, et al. (2010).

European Urology 58(3): 457-461.


Robot-assisted laparoscopic prostatectomy (RALP) has been disseminated widely, changing the knowledge of surgical anatomy of the prostate. The aim of our study is to demonstrate the feasibility of a new, purely intrafascial approach. The Bocciardi approach for RALP passes through the Douglas space, following a completely intrafascial plane without any dissection of the anterior compartment, which contains neurovascular bundles, Aphrodite’s veil, endopelvic fascia, the Santorini plexus, pubourethral ligaments, and all of the structures thought to play a role in maintenance of continence and potency. In this case series, we present our first five patients undergoing the Bocciardi approach for RALP. We report the results of our technique in three patients following two unsuccessful attempts. No perioperative major complication was recorded. Pathologic stage was pT2c in two patients and pT2a in one patient, with no positive surgical margin. The day after removing the catheter, two of the three patients reported use of a single, small safety pad, and one patient was discharged without any pad. One patient reported an erection the day after removing the catheter. The anatomic rationale for better results compared with traditional RALP is strong, but well-designed studies are needed to evaluate the advantages of our technique. © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.




“Does Prior Abdominal Surgery Influence Outcomes or Complications of Robotic-assisted Laparoscopic Radical Prostatectomy?”

Ginzburg, S., F. Hu, et al. (2010).



OBJECTIVES: To determine whether robotic-assisted laparoscopic radical prostatectomy (RALP) in patients with prior abdominal surgery is associated with increased operating times, positive surgical margins, or complications. METHODS: An institutional review board-approved retrospective review of a prospective, prostatectomy database was performed. Patients undergoing surgery between January 1, 2004, and February 29, 2008 were included. Transition from open retropubic prostatectomy to RALP took place through 2004, at which point all surgical candidates were offered RALP, regardless of prior surgical history. Learning curves from all surgeons were included. Patients with prior abdominal surgery were compared with those patients without prior surgery with respect to total operating time, robotic-assist time, surgical margin positivity, and rate of complications. RESULTS: A total of 1083 patients underwent RALP between January 1, 2004, and February 29, 2008, at our institution; of these, 839 had sufficient data available for analysis. In all, 251 (29.9%) patients had prior abdominal surgery, whereas 588 (70.1%) had no prior abdominal surgery. Total operating times were 209 and 204 minutes (P = .20), robotic console times were 165 and 163 minutes (P = .59), and surgical margin positivity was 21.1% and 27.2% (P = .08) for patients with and without prior abdominal surgery, respectively. The incidence of complications was 14.3% and 17.3% for patients with and without prior abdominal surgery (P = .33). CONCLUSIONS: Prior abdominal surgery was not associated with a statistically significant increase in overall operating time, robotic assist time, margin positivity, or incidence of complications in patients undergoing RALP. Robotic prostatectomy can be safely and satisfactorily performed in patients who have had a wide variety of prior abdominal surgery types.




“Does Previous Robot-assisted Radical Prostatectomy Experience Affect Outcomes at Robot-assisted Radical Cystectomy? Results from the International Robotic Cystectomy Consortium.”

Hayn, M. H., N. J. Hellenthal, et al. (2010).



OBJECTIVES: To evaluate the effect of previous robot-assisted radical prostatectomy (RARP) case volume on the outcomes of robot-assisted radical cystectomy. Little is known regarding the effect of previous robotic surgical experience on the implementation and execution of robot-assisted radical cystectomy. METHODS: Using the International Robotic Cystectomy Consortium database, 496 patients were identified who had undergone robot-assisted radical cystectomy by 21 surgeons at 14 institutions from 2003 to 2009. The surgeons were divided into 4 groups according to their previous RARP experience (</=50, 51-100, 101-150, and >150 cases). The overall operative time, blood loss, lymph node yield, pathologic stage, and surgical margin status were compared among the 4 groups using chi-square analysis. RESULTS: The mean operative time was 386 minutes (range 178-827). The mean estimated blood loss was 408 mL (range 25-3500). The operative time and blood loss were both significantly associated with previous RARP experience (P < .001). The mean lymph node count was 17.8 nodes (range 0-68). Lymph node yield and increased pathologic stage were significantly associated with previous RARP experience (P < .001). Finally, 34 (7.0%) of the 482 patients had a positive surgical margin. Margin status was not significantly associated with previous RARP experience (P = .089). CONCLUSIONS: Previous RARP case volume might affect the operative time, blood loss, and lymph node yield at robot-assisted radical cystectomy. In addition, surgeons with increased RARP experience operated on patients with more advanced tumors. Previous RARP experience, however, did not appear to affect the surgical margin status.




“Clavien Classification of Complications After the Initial Series of Robot-Assisted Radical Prostatectomy: The Cancer Institute of New Jersey/Robert Wood Johnson Medical School Experience.”

Jeong, J., E. Y. Choi, et al. (2010).

Journal of Endourology.


Abstract Purpose: To study the safety and feasibility of robot-assisted radical prostatectomy (RARP) for the surgical management of localized prostate cancer, we analyzed perioperative parameters and the pattern of complications in our patients who underwent RARP. Patients and Methods: After the performance of more than 600 RARP over a 4-year period by a single surgeon using the daVinci(R) robot system at the Cancer Institute of New Jersey/Robert Wood Johnson Medical School, we reviewed the medical records of the first 200 patients retrospectively. All patients were divided into four groups according to the order of case numbers to compare intergroup differences in preoperative characteristics and perioperative parameters. Perioperative complications were determined in all patients, and complications were classified according to the Clavien classification system. Results: The mean operative time was 212 minutes, and the mean blood loss was 189 mL. The mean length of hospital stay was 1.13 days. Overall, 12% (24 men) experienced various perioperative complications among the 200 patients. Of the total 24 patients, 5 (20.8%) men experienced intraoperative complications, and 19 (79.2%) men showed postoperative complications. Rectal injury occurred in two (8.3%) men, and the injury was repaired primarily using two-layer suture techniques without any sequelae. Three (12.5%) patients had femoral neuropathy, and urinary retention developed in 7 (25.0%) patients. Among our 200 patients, no transfusion was needed intraoperatively and postoperatively. There were nine (4.5%) patients in the Clavien grade I complications category, and another 9 (4.5%) men were classified as grade II complications. Six (3.0%) men had grade IIIb complications, and there were no grade IV or V complications. Conclusions: In our initial series of RARP procedures, we experienced low morbidity, with the overall complication rate of 12%. After implementing minor modifications, most of the early complications were prevented. Rectal injuries, if recognized intraoperatively, can be repaired primarily.




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

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

BJU International 106(3): 391-396.


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




“Impact of robotic training on surgical and pathologic outcomes during robot-assisted laparoscopic radical prostatectomy.”

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

Urology 76(2): 363-368.


OBJECTIVES: To prospectively compare outcomes during robotic prostatectomy between surgeons with formal training in either robotic prostatectomy (RALP) or laparoscopic prostatectomy (LRP). METHODS: A total of 286 robotic prostatectomies were performed by 12 urologists between August 2008 and March 2009 as part of a new robotic surgery program at one of the largest health maintenance organizations in the United States. Four surgeons had formal training in RALP and 8 had formal training in LRP. We prospectively compared surgical and pathologic outcomes between these 2 groups of surgeons. RESULTS: The 4 RALP surgeons performed 121 RALPs and the 8 LRP surgeons performed 165 RALPs. Patient demographics were similar between groups. The robot-naive group had significantly more clinical stage T1c than the robot-trained group (87.9% vs 74.4%, P = .003). Prostatectomy parameters were similar between the 2 groups of surgeons in terms of prostate size, Gleason score, pathologic stage, and estimated blood loss. The robot-trained surgeons had significantly lower overall positive margin rates (24% vs 34.6%, P = .05) and lower margin rates in T3 tumors (38.5% vs 61.8%, P = .07), which were approximately statistically significant. There was no difference in margin rates in T2 tumors. The robot-trained surgeons had significantly lower apical margin rates (8.3% vs 21.2%, P = .003) and lateral margin rates (1.7% vs 7.3%, P = .05). The robot-trained surgeons had 10%-15% shorter procedure times. There was no difference in complication rates. CONCLUSIONS: Formal RALP training may be beneficial for surgical and pathologic outcomes of RALP compared with formal LRP training during the initial implementation of a new robotics program.




“Radical prostatectomy in obese patients: Improved surgical outcomes in recent years.”

Lindner, U., N. Lawrentschuk, et al. (2010).

International Journal of Urology 17(8): 727-732.


Objectives: Obesity has been proposed as a risk factor for reduced disease-specific survival, increased positive surgical margin (PSM) and biochemical recurrence (BCR) after radical prostatectomy (RP) in patients with prostate cancer. The aim of this study was to clarify the relationship between obesity and surgical outcomes in patients undergoing RP. Methods: Medical records of 491 patients who underwent RP from 2004 to 2007 were retrieved from our institutional database. Patients were divided into three groups based on their body mass index (BMI): <25, 25-30 (overweight) and >30 kg/m (obese). Outcomes after RP were compared between the groups in terms of length of stay, perioperative complications, BCR, PSM and Gleason scores. Results: Age, stage and preoperative prostate-specific antigen were similar between BMI categories. Operating time was prolonged in obese patients (146 vs 135 min, P = 0.01) and blood loss was greater (mean estimated blood loss 640 vs 504 mL, P = 0.02), but did not translate into higher transfusion rates. Early complication rates, PSM rates and Gleason scores were not statistically different between the groups. Significant differences in late outcomes, such as the need for adjunct procedures or BCR (hazard ratio 0.44, 95% CI 0.18-1.09), were not shown. Conclusion: As surgical experience with high BMI patients has developed, RP appears to be a well tolerated procedure in contemporary series, irrespective of BMI. In particular, early outcome parameters, such as PSM and BCR rates, are similar. © 2010 The Japanese Urological Association.




“High body mass index does not affect outcomes following robotic assisted laparoscopic prostatectomy.”

Moskovic, D. J., H. J. Lavery, et al. (2010).

Can J Urol 17(4): 5291-5298.


INTRODUCTION: Given the anatomic constraints of obese patients, concern exists as to whether robotic assisted laparoscopic prostatectomy (RALP) is appropriate in patients with higher body mass index (BMI). We reviewed a large RALP database to determine if clinical outcomes are related to BMI. METHODS: The records of patients who underwent a RALP from 2003-2009 were reviewed. BMI stratifications were concordant with the Centers for Disease Control (CDC) standards: >/= 30, >/= 25 and < 30, and < 25 were classified as obese, overweight, and normal weight, respectively. Baseline, perioperative, histopathologic, and functional outcome data were collected. RESULTS: A total of 1420 patients were identified and BMI information was available for 1112 patients. Median BMI in the three strata was 23.5 (n = 270), 27.3 (n = 600), and 32.1 (n = 242). There were no significant differences in preoperative prostate specific antigen (PSA), clinical staging, and preoperative Gleason scores. Operating time was 6 minutes longer in the obese (p < 0.001) and prostate weight was 8 g greater (p < 0.001). Other perioperative factors were similar, including: EBL, pathologic stage and Gleason score and rates of positive surgical margins. The overall incidence of postoperative complications was similar between the three groups. Biochemical recurrence rates were similar among all patients, although there was a trend toward increased recurrence in the obese (p = 0.09). Recovery of erectile function and continence was similar regardless of BMI. CONCLUSIONS: RALP is an effective approach to prostatectomy in obese patients as perioperative and functional outcomes are almost identical across BMI strata. This supports the continued utilization of RALP in obese and overweight men.




“Minimally invasive radical prostatectomy: Perception vs. reality.”

Nirmal, T. J. and N. S. Kekre (2010).

Indian Journal of Urology 26(2): 318-319.




“Evaluating urinary continence and preoperative predictors of urinary continence after robot assisted laparoscopic radical prostatectomy.”

Novara, G., V. Ficarra, et al. (2010).

Journal of Urology 184(3): 1028-1033.


PURPOSE: We evaluated urinary continence using a validated questionnaire in a series of consecutive patients who underwent robot assisted laparoscopic radical prostatectomy, and identified the preoperative predictors of the return to urinary continence. MATERIALS AND METHODS: The clinical records of 308 consecutive patients who underwent robot assisted laparoscopic radical prostatectomy for clinically localized prostate cancer at a tertiary academic center were prospectively collected. All patients were continent before surgery. Urinary continence was evaluated using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form instrument. All of the patients reporting no leak in response to the question, “How often do you leak urine?” were defined as continent. RESULTS: A total of 273 patients (90%) were continent 12 months after robot assisted laparoscopic radical prostatectomy. Continent patients were significantly younger (61.4 +/- 6.4 vs 64.1 +/- 6.1 years, p = 0.02) than those who were incontinent. On univariable regression analysis patient age at surgery (OR 1.075, p = 0.024) and Charlson comorbidity index (OR 1.671, p = 0.007) were significantly associated with 12-month continence status. On multivariable analysis age (OR 1.076, p = 0.027) and Charlson comorbidity index (OR 1.635, p = 0.009) were independent predictors of continence rates. CONCLUSIONS: Using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form 90% of patients undergoing robot assisted laparoscopic radical prostatectomy reported no urine leak 12 months after surgery. Patient age at surgery and Charlson comorbidity index were independent predictors of the return to urinary continence, whereas notably no variable related to prostate cancer was significantly correlated with urinary continence.




“[Erectile dysfunction in patients with prostate cancer who have undergone surgery: Systematic review of literature.].”

Ruiz-Aragon, J., S. Marquez-Pelaez, et al. (2010).

Actas Urologicas Espanolas 34(8): 677-685.


OBJECTIVE: To assess erectile dysfunction in patients with prostate cancer undergoing surgery by radical prostatectomy, laparoscopic prostatectomy or robotic prostatectomy. MATERIAL AND METHODS: Systematic Review of literature based on a search strategy (2000-10) in MedLine, Embase, Cochrane Library, CRD, ECRI, and Hayes. Mesh terms used were Prostatectomy, “Prostatic Neoplasm, Transuretral Resection Prostate, Impotence and as free terms erectile dysfunction and prostatectomy. Studies included patients with prostate cancer underwent by prostatectomy radical with open surgery (retropubic), laparoscopic or robotic surgery. RESULTS: Ten observational studies with moderate quality and 29 case series with low quality were selected. Observational studies showed lower percentages of erectile dysfunction after intervention in the patients underwent robotic surgery (3-51%). Radical surgery (36-91%) and laparoscopic surgery showed higher values of impotence. In the studies that compared surgery versus radiotherapy, the results were better for radiotherapy (3-72% erectile dysfunction). In the case series, lower percentages of erectile dysfunction were shown in patients underwent to robotic surgery (22%), the following was for laparoscopic surgery (40%) and open radical prostatectomy (41.4%). CONCLUSIONS: This result should be considered with caution because of the low methodological quality of the studies included. However, the different surgical techniques assessed showed similar effects in the two types of studies included and we found that robotic surgery presented lower percentages of sexual impotence.




“Improvements in robot-assisted prostatectomy: The effect of surgeon experience and technical changes on oncologic and functional outcomes.”

Samadi, D. B., P. Muntner, et al. (2010).

Journal of Endourology 24(7): 1105-1110.


Purpose: To assess the effect of surgeon experience and technical modifications on functional and oncologic outcomes after robot-assisted laparoscopic prostatectomy (RALP). Patients and Methods: Data were available for 1181 of 1420 consecutive patients undergoing RALP by a single surgeon (DBS). Three techniques were evaluated. The “initial” technique included incision of the lateral endopelvic fascia, suture ligation of the dorsal venous complex (DVC), and anterior tennis-racquet bladder neck reconstruction (n? =? 590 procedures). The “intermediate” technique included a modified “curtain” nerve-sparing technique and incision of the DVC without previous ligation (n? =? 170). The “current” technique uses a posterior tennis-racquet bladder neck reconstruction (n? =? 421). Outcomes included continence and potency recovery and the presence of pT<sub>2</sub> surgical margins assessed in continuous fashion. Validated questionnaires were used to assess baseline and postoperative functional outcomes. Results: Continence rates improved between techniques at all evaluated time points, with 1-year continence rates of 88%, 93%, and 96% in the initial, intermediate, and current technique groups, respectively (Ptrend &lt;0.001). One-year potency rates, however, remained similar among the groups, with rates of 77%, 84%, and 79%, respectively (P? =? 0.58). pT<sub>2</sub> margin rates decreased continuously during the initial technique period, followed by a transient worsening of margin rates during the intermediate time period and a subsequent decrease during the period when the current technique was used. Conclusions: Increased experience with robot-assisted prostatectomy resulted in improvements in oncologic and functional outcomes. Modifications to robot-assisted prostatectomy techniques may aid in this improvement but are also associated with transient worsening of outcomes during the learning curve of the new technique. © 2010, Mary Ann Liebert, Inc.




“Does Robotic Technology Mitigate the Challenges of Large Prostate Size?”

Skolarus, T. A., R. C. Hedgepeth, et al. (2010).



Objectives: For radical prostatectomy, the advantages of robotic surgery may facilitate precise dissection and improve functional outcomes. However, patients with larger prostates may still pose increased challenges because of impaired visualization and mobility in the pelvis. For this reason, we undertook a study to better understand the relationships between large prostate size and robotic prostatectomy outcomes with respect to intraoperative and pathologic factors. Methods: Patients undergoing robotic-assisted radical prostatectomy from 2003 to 2008 at our institution were included in this retrospective study. Prostate size was categorized into 3 groups (<50, 50-100, >100 g). We compared surgical and quality of life (Expanded Prostate Cancer Index Composite [EPIC] scores) outcomes among groups using generalized linear models and chi-square testing. Results: Patients with the largest prostates had longer operative times (>100 vs <50 g, 250 vs 232 minutes, P < .01) and more blood loss (>100 vs <50 g, 250 vs 155 mL, P = .01). Conversely, these patients had fewer positive surgical margins and lower Gleason sums (both P < .01). Despite worse baseline irritative symptoms (>100 vs <50 g, 79.7 vs 90.0, P < .001) and sexual function (>100 vs <50 g, 38.2 vs 77.9, P < .001), these differences resolved at 3 months (P = .92, P = .88, respectively). Recovery of continence was relatively sluggish compared with that in patients with the smallest prostates (>100 vs <50 g; 44.0, 62.2, P = .03). Conclusions: Not surprisingly, larger prostate size was associated with increased operative times and blood loss, although of questionable clinical significance. While these patients appeared to benefit regarding irritative symptoms, recovery of continence was delayed. Longer follow-up is needed to further assess recovery. © 2010 Elsevier Inc. All rights reserved.




“Characteristics and management of erectile dysfunction after various treatments for prostate cancer.”

Soh, J., Y. Kaiho, et al. (2010).

International Journal of Urology 17(8): 689-697.




“Assessment of lymph node yield after pelvic lymph node dissection in men with prostate cancer: A comparison between robot-assisted radical prostatectomy and open radical prostatectomy in the modern era.”

Truesdale, M. D., D. J. Lee, et al. (2010).

Journal of Endourology 24(7): 1055-1060.


Background and Purpose: Studies of radical prostatectomy (RP) suggest that higher lymph node yield (LNY) improves tumor staging. Robot-assisted radical prostatectomy (RARP) is becoming increasingly popular, yet LNY data are not well reported. We compare LNY from contemporary open RP (ORP) with RARP at an academic center. Patients and Methods: A retrospective study was conducted of an Urologic Oncology Database. Between January 2005 and November 2009, 217 men underwent ORP with pelvic lymph node dissection (PLND); 99 underwent RARP with PLND by a single surgeon during the same period. Men were stratified according to the D’Amico risk criteria. For intermediate and high-risk disease, an extended PLND was performed. Patient demographic, operative, and pathologic variables were measured, and LNY was compared across groups. Results: No significant differences were seen between groups for race, body mass index, preoperative prostate-specific antigen level or biopsy Gleason score. Patients were younger for RARP vs ORP (P? =? 0.003) and had higher clinical tumor stage (P? =? 0.02). Operative time was longer (P? =? 0.03) and estimated blood loss was greater (P? <? 0.001) in the ORP group. Overall, only a borderline significant difference was seen in LNY between ORP and RARP (7.49 vs 6.35 nodes, respectively, P? =? 0.06). No difference was seen for intermediate and high-risk patients, with 7.7 vs 6.8 nodes for ORP and RARP, respectively (P? =? 0.27). The lymph node metastasis rate was 6.3%, with more positive nodes detected during ORP vs RARP: 19/217 (8.8%) vs 1/99 (1.0%), P? =? 0.009. Conclusions: No significant differences were seen in LNY during RARP and ORP for intermediate and high-risk men. For experienced surgeons, RARP can achieve equivalent LNY as ORP. A future study with a larger sample size is necessary to make a definitive statement of equivalence. © 2010, Mary Ann Liebert, Inc.




“Robotic Laparoendoscopic Single-Site Radical Prostatectomy: Technique and Early Outcomes.”

White, M. A., G. P. Haber, et al. (2010).

European Urology.


Background: Laparoendoscopic single-site (LESS) surgery is challenging. To help overcome current technical and ergonomic limitations, the da Vinci robotic platform can be applied to LESS. Objectives: Our aim was to describe the surgical technique and to report the early outcomes of robotic LESS (R-LESS) radical prostatectomy (RP). Design, setting, and participants: A retrospective review of prospectively captured R-LESS RP data was performed between May 2008 and May 2010. A total of 20 procedures were scheduled (12 with and 8 without pelvic lymph node dissection). Surgical procedure: R-LESS prostatectomy was performed using the methods outlined in the paper and in the supplemental video material. Interventions: All patients underwent R-LESS RP by one high-volume surgeon. Single-port access was achieved via a commercially available multichannel port. The da Vinci S and da Vinci Si surgical platform was used with pediatric and standard instruments. Measurements: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. Results and limitations: The mean age was 60.4 yr; body mass index was 25.4 kg/m<sup>2</sup>. The mean operative time was 189.5 min; estimated blood loss was 142.0 ml. The average length of stay was 2.7 d, and the visual analog pain score at discharge was 1.4 of 10. Four focal positive margins were encountered, with two occurring during the first three cases. Pathology revealed a Gleason score of 3 + 3 in 3 patients, 3 + 4 in 11 patients, 4 + 3 in 4 patients, and 4 + 4 in 2 patients. There were a total of four complications according to the Clavien system including one grade 1, two grade 2, and one grade 4. The median follow-up has been 4 mo (range: 1-24 mo). Study limitations include the small sample size, the short follow-up, and the lack of comparative cohort. Conclusions: The R-LESS RP is technically feasible and reduces some of the difficulties encountered with conventional LESS RP. © 2010 European Association of Urology.




“Robotic surgery techniques for obese patients.”

Zorn, K. C. (2010).

Canadian Urological Association Journal 4(4): 255-256.