Abstrakt Urologie Únor 2009

“Pelvic lymph node dissection and outcome of robot-assisted radical cystectomy for bladder carcinoma.” Gamboa, A. J., J. L. Young, et al. (2009).

Journal of Robotic Surgery: 1-6.


Introduction: Pelvic lymph node dissection (PLND) at the time of radical cystectomy for urothelial carcinoma of the bladder is critical for accurate staging and may improve oncologic outcomes. Minimally invasive approaches have been criticized for limiting the extent of the PLND. We reviewed our experience with PLND and its perioperative outcomes with robot-assisted laparoscopic radical cystectomy (RARC). Methods: Data were collected prospectively from 50 patients scheduled for RARC. Included in the analysis were patients who had RARC and a standard PLND. The entire extirpative portion of the procedure was performed using the da Vinci Robot (Intuitive Surgical, Sunnyvale, CA, USA). Results: A total of 41 patients were included in the study: 30 men and 11 women with a mean age of 69.7 years (range 49-85) and a mean body mass index of 26.9 (range 19.5-43.7). The median total operative time was 497.77 min (320-805). The mean estimated blood loss was 253.66 ml (range 50-700). The transfusion rate was 44% (18 out of 41) ranging from 0 to 4 units (median 0 units of blood). The mean total number of lymph nodes retrieved was 25.07 (range 4-68). Nodal metastases were seen in 14.63% (6/41). Rate of positive surgical margin was 4.87% (2/41). The median length of hospital stay was 8 days (5-37). The median duration of nasogastric tube, time to ambulation, first clear liquid intake, passage of colonic gas, time to bowel movement, and start of solid food intake were 1 (0-5), 2 (1-7), 3 (2-10), 4 (1-6), 5 (2-11) and 6 days (3-24), respectively. Conclusion: An adequate PLND, comparable with that recommended for open surgery, can be performed safely with robot assistance. The perioperative outcomes were likewise comparable with that of the gold standard, open cystectomy. © 2009 The Author(s).




“Robot-assisted ureterectomy and ureteral reconstruction for urothelial carcinoma.”

Glinianski, M., K. A. Guru, et al. (2009).

Journal of Endourology 23(1): 97-100.

Background and Purpose: Urothelial carcinoma of the distal ureter can be managed by ureterectomy followed by reconstruction of the urinary system. We review our experience with robot-assisted ureterectomy. Patients and Methods: Nine consecutive patients who were candidates for ureterectomy underwent robot-assisted surgery between 7/8/2005 and 7/25/2006. Patient characteristics, intraoperative parameters, and short-term outcomes were retrospectively reviewed. Results: Mean operative time was 252 minutes. The mean blood loss was 44 mL, and no patient needed a transfusion. The mean hospital stay was 1.5 days. Six patients needed a psoas hitch; one patient each underwent a primary ureteral anastomosis, a direct ureteral reimplant into the dome of the bladder, and distal ureterectomy for tumor in a ureteral stump after nephrectomy. The ureteral reimplant was performed intravesically in one patient and extravesically in five patients. A bladder cuff was excised in all patients who were undergoing a distal ureterectomy. All surgical margins were negative, and five patients had high-grade tumor. A ureteral stricture developed in one patient, and a patient experienced aspiration pneumonia in the postoperative period. Conclusions: Robot-assisted ureterectomy and ureteral reconstruction is safe and feasible, and offers patients the advantages of minimally invasive surgery. Future studies with additional patients and longer follow-up will determine the oncologic effectiveness of this procedure. © Mary Ann Liebert, Inc. 2009.




“Pediatric robotic-assisted laparoscopic diverticulectomy.”

Meeks, J. J., J. A. Hagerty, et al. (2009).

Urology 73(2): 299-301; discussion 301.

Congenital bladder diverticula are rare anomalies of the bladder. Patients present with infection, hematuria, and/or urinary obstruction. We report on the case of a 12-year-old boy who developed gross hematuria and recurrent infection owing to a 12-cm bladder diverticulum. Robotic-assisted laparoscopic diverticulectomy was performed. We describe the first reported robotic-assisted laparoscopic diverticulectomy in a pediatric patient.




“Robotic-assisted laparoscopic radical cystectomy: where do we stand?”

Novara, G. and V. Ficarra (2009).

Int J Clin Pract 63(2): 185-8.




“Robotic Partial Nephrectomy with Sliding-Clip Renorrhaphy: Technique and Outcomes.”

Benway, B. M., A. J. Wang, et al. (2009).

European Urology 55(3): 592-599.

Background: Robotic partial nephrectomy (RPN) is emerging as an alternative to traditional laparoscopic partial nephrectomy (LPN). Despite the potential advantages of the robotic approach, renorrhaphy remains a challenging portion of the procedure. Objective: To present our technique and outcomes for RPN, including sliding-clip renorrhaphy. Design, setting, and participants: Between 2007 and 2008, 50 patients underwent RPN performed by a single attending surgeon. Surgical procedure: In this paper, we describe our technique for RPN, including a sliding-clip renorrhaphy, which is distinguished by the use of Weck Hem-O-Lock clips that are slid into place under complete control of the surgeon seated at the console and secured with a LapraTy clip. For the first 13 procedures, traditional tied-suture or assistant-placed clip closures were performed; sliding-clip renorrhaphy was performed in the remaining 37 cases. Results and limitations: Mean tumor size was 2.5 cm. Mean operative time was 145.3 min, and mean overall warm ischemia time was 17.8 min. Mean estimated blood loss was 140.3 ml. The learning curve for overall operative time was 19 cases; the learning curve for portions of the case performed under warm ischemia (including tumor resection and renorrhaphy) was 26 cases. The introduction of a sliding-clip renorrhaphy produced significant reductions in overall operative time and warm ischemia time, while blood loss and hospital stay remained stable over our experience. Limitations of RPN include cost and increased reliance on the bedside assistant. Conclusions: Sliding-clip renorrhaphy provides an efficient and effective repair that is under nearly complete control of the surgeon. This technique appears to contribute to significantly shorter overall operative times and, perhaps most critically, to shorter warm ischemia times. The learning curve for RPN using this technique appears to be foreshortened compared with LPN. © 2008 European Association of Urology.




“Robotic-Assisted Laparoscopic Pyeloplasty and Nephropexy for Ureteropelvic Junction Obstruction and Nephroptosis.”

Boylu, U., B. R. Lee, et al. (2009).

J Laparoendosc Adv Surg Tech A.

Abstract A 22-year-old female was referred with right flank pain and recurrent urinary infections. Flank pain was persistent while standing and relieved upon supine position. Intravenous urography demonstrated change of position with descent approximately 6-7 cm as the patient moved from the supine to the erect position. Diuretic renography corroborated the finding of right ureteropelvic junction obstruction (UPJO). A robotic-assisted laparoscopic dismembered pyeloplasty with simultaneous nephropexy was performed. The proximal ureter appeared to course posterior to the renal vein and then anterior to the lower pole renal artery. There was a significant “nutcracker effect” to the proximal ureter, which was causing the patient’s UPJO, and the concomitant nephroptosis contributed to increase the degree of obstruction. The robotic-assisted laparoscopic pyeloplasty and nephropexy offer advantages for patients and surgeons and can be used in challenging cases with an efficacy similar to that of open repair. The robotic-assisted laparoscopic pyeloplasty is the evolving standard for UPJO, especially in the presence of crossing vessels.




“Ureteropelvic Junction Obstruction Secondary to Crossing Vessels-To Transpose or Not? The Robotic Experience.”

Boylu, U., M. Oommen, et al. (2009). J Urol.

PURPOSE: We compared the surgical outcomes of robot assisted laparoscopic dismembered pyeloplasty in patients presenting with anterior crossing vessels with and without transposition of the crossing vessel. MATERIALS AND METHODS: A total of 107 patients with ureteropelvic junction obstruction underwent robot assisted laparoscopic dismembered pyeloplasty. Evaluation of surgical success was based on validated pain scores, diuretic renography and imaging results, including excretory urography, computerized tomography or ultrasound. RESULTS: Anterior crossing vessels were identified in 48 patients (44.9%) and vessels were transposed in 18 (37.5%) (group 1). No transposition was performed in 30 patients (62.5%) (group 2). Mean radiological followup was 52.9 weeks in group 1 and 65.3 weeks in group 2 (p = 0.181). Mean pain score on a scale of 10 was 0.82 in group 1 and 0.74 in group 2 (p = 0.917). A Whitaker test performed in 3 patients with persistent pain was negative. Preoperatively mean differential function on the affected side was 35.1% in group 1 and 36.9% in group 2 (p = 0.133). Half-time was calculated as a mean of 46.3 minutes in group 1 and 49.4 minutes in group 2 (p = 0.541). In groups 1 and 2 mean postoperative differential function improved to 41.1% and 40.9%, and mean half-time improved to 7.43 and 8.03 minutes, respectively (p = 0.491). A comparison of preoperative and postoperative differential function, and half-time in each group showed a statistically significant difference. The radiographic and symptomatic success rate was 100% with no open conversion and recurrence. CONCLUSIONS: Comparison of robot assisted laparoscopic dismembered pyeloplasty outcomes revealed similar success rates in terms of the change in symptoms and renal function in patients with or without anterior crossing vessel transposition. Transposition of crossing vessel should only be performed when the anatomical relation dictates and it should be an intraoperative decision.




“Intraoperative ultrasound: application in pediatric pyeloplasty.”

Ginger, V. A. and T. S. Lendvay (2009).

Urology 73(2): 377-9; discussion 379.

OBJECTIVES: To describe a simple method of using a readily available portable ultrasound device to confirm distal stent placement for antegrade placed stents. Antegrade placement of internal double-J ureteral stents during open or laparoscopic pyeloplasty has become an alternative to retrograde placement but might be less reliable owing to the lack of confirmation of the distal stent position. METHODS: The SonoSite S-Nerve ultrasound system was used with a L38 x 10-5 MHz linear array transducer to evaluate the distal curl of the double-J stent within the bladder intraoperatively during da Vinci robotic-assisted pyeloplasty. The patient did not require repositioning or removal of the robotic arms. RESULTS: Visualization of the stent was successful in all patients with an age range of 8 months to 17 years. CONCLUSIONS: We present the first published method of using ultrasonography to assess and confirm distal stent placement intraoperatively during antegrade stent placement. This simple method uses off-the-shelf equipment available within most operating rooms. In addition, intraoperative ultrasound confirmation of double-J stent placement allows for the ease of antegrade placement with the distal visual confirmation of the stent position without necessitating fluoroscopy or patient repositioning.




“A prospective comparison of laparoscopic and robotic radical nephrectomy for T1-2N0M0 renal cell carcinoma.”

Hemal, A. K. and A. Kumar (2009).

World J Urol 27(1): 89-94.

OBJECTIVES: We prospectively evaluated the safety, feasibility, and efficiency of robotic radical nephrectomy (RRN) for localized renal tumors (T1-2N0M0) and compared this with laparoscopic radical nephrectomy (LRN). MATERIALS AND METHODS: Between October 2006 to August 2007, a prospective data analysis of 15 cases of renal cell carcinoma (RCC) stage T1-2N0M0, undergoing RRN was done. These patients were compared with a contemporary cohort of 15 patients of RCC with clinical stage T1-2N0M0, undergoing LRN. To keep comparison robust, all cases were performed by a single surgeon. Demographic, intra-operative, post-operative outcomes, pathological characteristics and follow-up data of the two groups were recorded and analyzed statistically. RESULTS: Patients in group A (RRN) experienced significantly (P = 0.001) long operating time than group B (LRN). However, mean estimated blood loss, intra-operative and post-operative complications, blood transfusion rate, analgesic requirement, hospital stay and convalescence were comparable in two groups (P < 0.05). There was one conversion to open surgery in group A, and none in group B. The mean follow-up was comparable in two groups (8.3 and 9.1 months, respectively, in group A and B, P = 0.09). There were no local, port-site or distal recurrences in either group. CONCLUSIONS: Robotic radical nephrectomy is a safe, feasible and effective for performing radical nephrectomy for localized RCC. Both groups (RRN and LRN) had comparable intra-operative, peri-operative, post-operative and oncological outcomes except for longer operating time with increased cost for RRN. In this comparative study, there were no outstanding benefits of RRN observed over LRN for localized RCC.




“Robotic-assisted laparoscopic partial nephrectomy: surgical technique and clinical outcomes at 1 year.” Ho, H., C. Schwentner, et al. (2009).

BJU Int 103(5): 663-8.

OBJECTIVE: To report our surgical technique of robotic-assisted laparoscopic partial nephrectomy (RLPN) for renal tumours of <7 cm and present their clinical outcomes, as minimally invasive PN is an increasingly viable option for small renal tumours. PATIENTS AND METHODS: From July 2005 to December 2006, 20 consecutive patients (mean age 58.2 years, sd 7.9) had RLPN and a follow-up of > or =1 year, all surgery being undertaken by one surgeon. All cases were elective except in one patient with a solitary kidney. We used the three-arm da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA) in a four-port, transperitoneal approach. Transient vascular occlusion was applied in all cases using a tourniquet technique. The tumour was excised with a 5-mm margin using cold-cut scissors, and the margins were assessed by frozen sections. The specimen was placed in an impervious bag for subsequent removal via the camera port. Under direct vision, we repaired all pelvicalyceal system entries with absorbable sutures. After the entire tumour bed surface was lined with Floseal (Baxter Healthcare, Deerfield, IL, ISA) the capsule/parenchyma was closed with running suture, reinforced by haemostatic clips. RESULTS: The mean (sd) operative and warm ischaemia times were 82.7 (17.0) and 21.7 (2.4) min, respectively, and the mean estimated blood loss was 189 (32) mL. There were no intraoperative complications or conversion to open surgery. There was also no bleeding after surgery, perinephric haematoma or urinary leakage. The mean (sd) tumour size was 30.2 (2.4) mm, while margins were negative in all cases of malignancy. At the 1-year follow-up there was no local recurrence, renal functional deterioration or late surgical complications. CONCLUSIONS: Our RLPN technique is a safe and feasible option for small renal tumours. Reproducible technique and good team co-ordination are pivotal for obtaining good oncological and surgical outcomes.




“Laparo-endoscopic single-site surgery: preliminary advances in renal surgery.”

Kommu, S. S., J. H. Kaouk, et al. (2009).

BJU Int.

We reviewed the preliminary advances in laparo-endoscopic single-site surgery (LESS) as applied to renal surgery, and analyzed current publications based on animal models and human patients. We searched published reports in major urological meeting abstracts, Embase and Medline (1966 to 25 August 2008), with no language restrictions. Keyword searches included: ‘scarless’, ‘scar free’, ‘single port/trocar/incision’, ‘intraumbilical’, and ‘transumbilical’, ‘natural orifice transluminal endoscopic surgery’ (NOTES), ‘SILS’, ‘OPUS’ and ‘LESS’. The lessons learnt from the studies using the porcine model are that further advances in instrumentation are essential to achieve optimum results, and that testing survival in animals is also necessary to further expand the NOTES and LESS techniques. Further advances in instrument technology together with increasing experience in NOTES and LESS approaches have driven the transition from porcine models to human patients. In the latter, studies show that the techniques are feasible provided that both optimal surgical technical expertise with advanced skills, and optimal instrumentation, are available. The next step towards minimal access/minimally invasive urological surgery is NOTES and LESS. It is inevitable that LESS will be extended to involve more complex and technically demanding procedures such as laparoscopic radical prostatectomy and partial nephrectomy.




“Robot assisted laparoscopic partial nephrectomy: a viable and safe option in children.”

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

J Urol 181(2): 823-8; discussion 828-9.

PURPOSE: The safety, benefits and usefulness of laparoscopic partial nephrectomy have been demonstrated in the pediatric population. We describe our technique, and determine the safety and feasibility of robot assisted laparoscopic partial nephrectomy based on our initial experience. MATERIALS AND METHODS: We retrospectively reviewed robot assisted laparoscopic partial nephrectomy performed at our institution between 2002 and 2005. The technique was conducted via a transperitoneal approach with the da Vinci Surgical System using standard laparoscopic procedural steps. Clinical indicators of outcomes included estimated blood loss, complications, in hospital narcotic use and length of stay. RESULTS: Robot assisted laparoscopic partial nephrectomy was completed successfully in 9 cases. Mean patient age was 7.2 years and mean followup was 6 months. Mean operative time was 275 minutes and mean estimated blood loss was 49 ml. Operative times improved significantly with experience. Overall patients had a mean hospitalization of 2.9 days and required 1.3 mg morphine per kg. All patients had a normal remaining renal moiety confirmed on Doppler ultrasound. The only complication was an asymptomatic urinoma discovered on ultrasound, which was treated with percutaneous drainage and ultimately resolved. CONCLUSIONS: Our initial experience shows the safety and feasibility of robot assisted laparoscopic partial nephrectomy in children. Operative time decreases with experience. The enhanced visualization and dexterity of a robotic system potentially offer improved efficiency and safety over standard laparoscopy. Robot assisted laparoscopy is an option for partial nephrectomy and may become the minimally invasive treatment of choice.




“Bypass pyeloplasty: Description of a procedure and initial results.”

Mesrobian, H. G. O. (2009).

Journal of Pediatric Urology 5(1): 34-36.

Introduction and objective: Dismembered pyeloplasty is the surgical technique of choice for open, laparoscopic and/or robot-assisted repair of ureteropelvic junction obstruction (UPJO). We describe a new technique, bypass pyeloplasty, ideally suited for the high inserting ureter, and present initial results. Patients and methods: A wide 1-2-cm side-to-side anastomosis is created between the dilated and elastic portion of the ureter just distal to the UPJO and the lower and dependent portion of the hydronephrotic renal pelvis. The UPJ is not disturbed and the renal pelvis is not surgically reduced. Since 2004, of 27 patients requiring surgery for UPJO, 7 underwent bypass pyeloplasty. The indications for surgery included increasing hydronephrosis or decreasing individual renal function in four, pain in two and pyelonephritis in one. The remaining 20 underwent a classic dismembered pyeloplasty. Results: During a mean follow-up of 26 months, the anteroposterior diameter of the repaired kidney decreased by a mean of 55%. The individual renal function in the repaired kidney improved in two and remained stable in the remainder. Conclusion: These favorable initial results justify further exploration of this simplified technique and its adaptation for laparoscopic and robot-assisted approaches. Bypass pyeloplasty may be a more physiologic procedure in patients with mid to high insertion of the ureter. © 2008 Journal of Pediatric Urology Company.




“Robotic-assisted laparoscopic partial nephrectomy: initial clinical experience.”

Michli, E. E. and R. O. Parra (2009).

Urology 73(2): 302-5.

OBJECTIVES: To report on our initial experience with robotic-assisted partial nephrectomy. Laparoscopic partial nephrectomy requires experience and a lengthy learning curve to successfully accomplish tumor excision and renal reconstruction, which may adversely prolong the ischemia time. The advent of robotic-assisted laparoscopic surgery has proved successful in prostate cancer surgery, encouraging a growing number of centers to apply this technology to complex renal surgery. METHODS: A total of 20 consecutive patients underwent robotic-assisted partial nephrectomy from September 2007 to April 2008. The surgical technique we used followed the standard 4-port laparoscopic partial nephrectomy technique. Renal hilum clamping was used in 12 cases. The demographic data and perioperative outcomes were retrospectively reviewed. RESULTS: The mean patient age and body mass index was 66 years and 29 kg/m(2), respectively. The mean tumor size was 2.7 cm. The mean operative and warm ischemia time was 142 and 28 minutes, respectively. The mean estimated blood loss was 263 mL, and 3 patients required a blood transfusion. One intraoperative complication required open conversion. Two postoperative complications were observed; 1 patient developed a pulmonary embolism and 1 developed an abscess at the resection site. The average hospital stay was 2.8 days. Pathologic examination of the lesions revealed 14 cases of renal cell carcinoma and 6 of benign lesions. All resection margins were free of tumor. CONCLUSIONS: The results of our study have shown that robotic partial nephrectomy is safe and practical for patients with small renal tumors considered candidates for open partial nephrectomy. In our experience, the procedure can be performed with safe ischemia time and offers all the advantages of a minimally invasive procedure.




“Retroperitoneal robotic renal surgery: technique and early results.”

Patel, M. N., S. A. Kaul, et al. (2009).

Journal of Robotic Surgery: 1-5.

We describe a robotic retroperitoneal approach to renal surgery, optimized in porcine and cadaveric models, and applied to human patients. A retroperitoneal approach for robotic kidney surgery was developed in nonsurvival porcine and a fresh cadaver models, and then utilized in ten patients (three partial nephrectomy, three radical nephrectomy, two simple nephrectomy, one pyeloplasty, one cryoablation). Retroperitoneal access was successfully achieved for robotic renal procedures in six pigs and a human cadaver. Ten human patients (mean age 56 years, range 36-72 years) then underwent a successful retroperitoneal approach for robotic renal surgery. Mean console time was 166 (120-300) min. Mean blood loss was 82 (50-100) ml and average hospital stay was 2.6 (1-5) days. Pathology demonstrated clear cell renal cell carcinoma (four), papillary renal cell carcinoma (two), and xanthogranulomatous pyelonephritis (two). One patient with xanthogranulomatous pyelonephritis required open conversion for failure to progress due to dense adhesions. A retroperitoneal approach is a safe and feasible alternative to a transperitoneal approach for robotic renal surgery, including radical nephrectomy, partial nephrectomy, pyeloplasty, and cryoablation. © 2009 Springer-Verlag London Ltd.




“Computed tomography angiogram: Accuracy in renal surgery.”

Rabah, D. M., N. Al-Hathal, et al. (2009).

International Journal of Urology 16(1): 58-60.

Objectives: To determine the sensitivity and specificity of computed tomography angiogram (CTA) in detecting number and location of renal arteries and veins as well as crossing vessels causing uretero-pelvic junction obstruction (UPJO), and to determine if this can be used in decision-making algorithms for treatment of UPJO. Methods: A prospective study was carried out in patients undergoing open, laparoscopic and robotic renal surgery from April 2005 until October 2006. All patients were imaged using CTA with 1.25 collimation of arterial and venous phases. Each multi-detector CTA was then read by one radiologist and his results were compared prospectively with the actual intra-operative findings. Results: Overall, 118 patients were included. CTA had 93% sensitivity, 77% specificity and 90% overall accuracy for detecting a single renal artery, and 76% sensitivity, 92% specificity and 90% overall accuracy for detecting two or more renal arteries (Pearson ?2 = 0.001). There was 95% sensitivity, 84% specificity and 85% overall accuracy for detecting the number of renal veins. CTA had 100% overall accuracy in detecting early dividing renal artery (defined as less than 1.5 cm branching from origin), and 83.3% sensitivity, specificity and overall accuracy in detecting crossing vessels at UPJ. The percentage of surgeons stating CTA to be helpful as pre-operative diagnostic tool was 85%. Conclusion: Computed tomography angiogram is simple, quick and can provide an accurate pre-operative renal vascular anatomy in terms of number and location of renal vessels, early dividing renal arteries and crossing vessels at UPJ. © 2008 The Japanese Urological Association.




“Maximizing console surgeon independence during robot-assisted renal surgery by using the fourth arm and TileProâ„¢.”

Rogers, C. G., R. Laungani, et al. (2009).

Journal of Endourology 23(1): 115-121.

Purpose: We describe multiple uses of the fourth robotic arm and TilePro™ on the da Vinci® S surgical system to maximize console surgeon independence from the assistant during robot-assisted renal surgery. Materials and Methods: We prospectively evaluated the use of the fourth robotic arm and TilePro on the da Vinci S during robot-assisted radical nephrectomy (RRN) and robot-assisted partial nephrectomy (RPN). The fourth robotic arm was used to provide kidney retraction, place the renal hilum on stretch, control vascular structures, apply and remove bulldog clamps during partial nephrectomy, and secure renal capsular stitches. TilePro was used to project intraoperative ultrasonography and preoperative CT images onto the console screen. Results: From January 2006 to June 2008, 90 robot-assisted kidney procedures were performed, of which the fourth robotic arm was used in 46 cases (RRN, 18; RPN, 24; nephroureterectomy, 4). The fourth robotic arm facilitated consistent kidney retraction for dissection of the renal hilum and mobilization of the kidney. The robotic Hem-o-Lok clip applier effectively controlled renal hilar vessels during eight RPN cases and secured renal capsular stitches during two RPN cases. Bulldog clamps were successfully applied to the renal artery during RPN using the fourth arm in two cases. TilePro was used during 22 RPN cases to project intraoperative ultrasonographic images and preoperative CT images onto the console screen as a picture-on-picture image to guide tumor resection. Conclusions: Robotic instruments used with the fourth robotic arm may give the console surgeon greater independence from the assistant during robot-assisted kidney surgery by facilitating steps such as kidney retraction, hilar dissection, and vascular control. The TilePro feature of the da Vinci S can be used to project intraoperative ultrasonography and preoperative imaging onto the console screen, potentially guiding tumor localization and resection during RPN without the need to leave the console to view external images. © Mary Ann Liebert, Inc. 2009.




“Augmented Reality During Robot-assisted Laparoscopic Partial Nephrectomy: Toward Real-Time 3D-CT to Stereoscopic Video Registration.”

Su, L. M., B. P. Vagvolgyi, et al.


Objectives: To investigate a markerless tracking system for real-time stereo-endoscopic visualization of preoperative computed tomographic imaging as an augmented display during robot-assisted laparoscopic partial nephrectomy. Methods: Stereoscopic video segments of a patient undergoing robot-assisted laparoscopic partial nephrectomy for tumor and another for a partial staghorn renal calculus were processed to evaluate the performance of a three-dimensional (3D)-to-3D registration algorithm. After both cases, we registered a segment of the video recording to the corresponding preoperative 3D-computed tomography image. After calibrating the camera and overlay, 3D-to-3D registration was created between the model and the surgical recording using a modified iterative closest point technique. Image-based tracking technology tracked selected fixed points on the kidney surface to augment the image-to-model registration. Results: Our investigation has demonstrated that we can identify and track the kidney surface in real time when applied to intraoperative video recordings and overlay the 3D models of the kidney, tumor (or stone), and collecting system semitransparently. Using a basic computer research platform, we achieved an update rate of 10 Hz and an overlay latency of 4 frames. The accuracy of the 3D registration was 1 mm. Conclusions: Augmented reality overlay of reconstructed 3D-computed tomography images onto real-time stereo video footage is possible using iterative closest point and image-based surface tracking technology that does not use external navigation tracking systems or preplaced surface markers. Additional studies are needed to assess the precision and to achieve fully automated registration and display for intraoperative use. © 2009 Elsevier Inc. All rights reserved.




“Robotic Partial Nephrectomy Versus Laparoscopic Partial Nephrectomy for Renal Cell Carcinoma: Single-Surgeon Analysis of >100 Consecutive Procedures.”

Wang, A. J. and S. B. Bhayani (2009).

Urology 73(2): 306-310.

Objectives: To compare a single-surgeon experience of laparoscopic partial nephrectomy (LPN) and robotic-assisted partial nephrectomy (RPN) in 102 consecutive patients. Methods: The clinical, pathologic, and follow-up information from 102 consecutive procedures (40 RPNs and 62 LPNs) was reviewed. Results: No statistically significant differences were found between the groups with regard to age, body mass index, or American Society of Anesthesiologists score. No significant difference was found between the estimated blood loss (136 vs 173 mL), tumor size (2.5 vs 2.4 cm), need for pelvicaliceal repair (56% for both), and positive margin rate (1 vs 1 patient) between RPN and LPN, respectively. The mean total number of trocars in the robotic group was greater than the laparoscopic group (4.6 vs 3.2, P = .01). The mean total operative time (140 vs 156 minutes, P = .04), warm ischemia time (19 vs 25 minutes, P = .03), and length of stay (2.5 vs 2.9 days, P = .03) were significantly shorter for RPN than for LPN, respectively. Conclusions: RPN can produce results comparable to LPN but has disadvantages, such as cost and assistant control of the renal hilum. Additional randomized trials are needed. © 2009 Elsevier Inc. All rights reserved.




“A transition to laparoendoscopic single-site surgery (LESS) radical prostatectomy: Human cadaver experimental and initial clinical experience.”

Barret, E., R. Sanchez-Salas, et al. (2009).

Journal of Endourology 23(1): 135-140.

Background and Purpose: Laparoendoscopic single-site surgery (LESS) represents a novel approach to abdominal surgery. Several applications have already been described. Drawbacks include limited range of motion and need for articulated instruments. Robotic technology could overcome such technical difficulties. We report our experience with LESS radical prostatectomy (LESS-RP) in a cadaver and LESS robot-assisted radical prostatectomy (LESS-RARP) in a human patient. Material and Methods: Standard laparoscopic instruments (SLI) and articulated laparoscopic instruments were used in the cadaveric LESS-RP. The da Vinci system was used in the LESS-RARP. Both procedures reproduced standard extraperitoneal laparoscopic prostatectomy as performed at Institut Montsouris. Control of the dorsal venous complex (DVC) and urethrovesical anastomosis (UVA) were key elements evaluated for feasibility. Results: Cadaveric model: Total operative time (TOT) was 160 minutes, with 5 minutes for the DVC (one stitch) and 35 minutes for the UVA (six stitches). Although articulated instruments were helpful in the operation, SLI remained essential for the procedure. Clinical experience: LESS-RARP was performed for T1c prostate cancer. TOT was 150 minutes, including 5 minutes for the DVC (one figure-of-eight stitch) and 30 minutes for the UVA (six interrupted stitches). Blood loss was 500 mL. Bilateral neurovascular preservation was performed, and results of final pathologic examination showed negative surgical margins. Conclusions: The human cadaver is an adequate model for LESS-RP, and LESS-RARP is feasible to be performed in the clinical arena. The synergy of robotic technology and LESS represents a new generation of surgery. © Mary Ann Liebert, Inc. 2009.




“Short- and long-term complications of open radical prostatectomy according to the Clavien classification system.”

Constantinides, C. A., S. I. Tyritzis, et al. (2009).

 BJU Int 103(3): 336-40.

OBJECTIVE: To assess the use of the Clavien classification system in documenting the complications related to open retropubic radical prostatectomy (RRP). PATIENTS AND METHODS: The medical records of 995 patients, who had open RRP during a period of 7 years, were reviewed retrospectively. Short- and long-term complications were classified according to the recently revised Clavien classification system. We also compared the results with a recently reported series of laparoscopic and robotic RRP. RESULTS: The overall complication rate was 26.9%; Grade I, Id, II, IIIa, IIIb and V complications were recorded in 3.4%, 3.9%, 12.8%, 2.6%, 3.8% and 0.3% of cases, respectively. Rectal injuries (10) and postoperative wound infections (24) were included in the Grade I category. Anastomotic leakage was recorded in 39 patients and rated as Grade Id. Grade II included cases of deep vein thrombosis (11), urinary tract infections (42), lymphorrhoeas (22) and haemorrhage requiring transfusion (53). Anastomotic strictures (26) and incisional hernias (38) were included in Grade IIIa and IIIb, respectively. Pulmonary embolism was fatal for three patients (0.3%) of Grade IV and V. CONCLUSIONS: To avoid incoherence in reporting morbidity data, a reproducible and practical classification system is necessary. The Clavien system could provide, after refinement and validation, a common language among urologists.




“Athermal early retrograde release of the neurovascular bundle during nerve-sparing robotic-assisted laparoscopic radical prostatectomy.”

Coughlin, G., P. P. Dangle, et al. (2009).

Journal of Robotic Surgery: 1-5.

While cancer control is the primary objective of radical prostatectomy, maintenance of sexual function is a priority for the majority of men presenting with prostate cancer. Preservation of the neurovascular bundles is the challenging and critical step of radical prostatectomy with regards to maintenance of potency. The objective of this study is to describe the surgical steps of our hybrid technique: athermal early retrograde release of the neurovascular bundle during nerve-sparing robotic-assisted laparoscopic radical prostatectomy. This technique involves releasing the neurovascular bundle in a retrograde direction from the apex toward the base of the prostate, during an antegrade prostatectomy. It is a hybrid of the traditional open and the laparoscopic approaches to nerve sparing. With this approach we are able to clearly delineate the path of the bundle and avoid inadvertently injuring it when controlling the prostatic pedicle. Our hybrid nerve-sparing technique combines aspects of the traditional open anatomical approach with those of the laparoscopic antegrade approach. The benefits of robotic technology allow a retrograde neurovascular bundle dissection to be performed during an antegrade radical prostatectomy. © 2009 Springer-Verlag London Ltd.




“Retropubic, Laparoscopic, and Robot-Assisted Radical Prostatectomy: A Systematic Review and Cumulative Analysis of Comparative Studies.”

Ficarra, V., G. Novara, et al.

European Urology.

Context: Despite the wide diffusion of laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP), only few studies comparing the results of these techniques with the retropubic radical prostatectomy (RRP) are currently available. Objective: To evaluate the perioperative, functional, and oncologic results in the comparative studies evaluating RRP, LRP, and RALP. Evidence acquisition: A systematic review of the literature was performed in January 2008, searching Medline, Embase, and Web of Science databases. A “free-text” protocol using the term radical prostatectomy was applied. Some 4000 records were retrieved from the Medline database; 2265 records were retrieved from the Embase database;, and 4219 records were retrieved from the Web of Science database. Three of the authors reviewed the records to identify comparative studies. A cumulative analysis was conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK). Evidence synthesis: Thirty-seven comparative studies were identified in the literature search, including a single, randomised, controlled trial. With regard to the perioperative outcome, LRP and RALP were more time consuming than RRP, especially in the initial steps of the learning curve, but blood loss, transfusion rates, catheterisation time, hospitalisation duration, and complication rates all favoured LRP. With regard to the functional results, LRP and RRP showed similar continence and potency rates. Similarly, no significant differences were identified between LRP and RALP, while a single, nonrandomised, prospective study suggested advantages in terms of both continence and potency recovery after RALP, compared with RRP. With regard to the oncologic outcome, LRP and RALP were associated with positive surgical margin rates similar to those of RRP. Conclusions: The quality of the available comparative studies was not excellent. LRP and RALP are followed by significantly lower blood loss and transfusion rates, but the available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. Further high-quality, prospective, multicentre, comparative studies are needed. © 2009 European Association of Urology.




“Long-term impact of a robot assisted laparoscopic prostatectomy mini fellowship training program on postgraduate urological practice patterns.”

Gamboa, A. J., R. T. Santos, et al. (2009).

J Urol 181(2): 778-82.

PURPOSE: Robot assisted laparoscopic prostatectomy has stimulated a great deal of interest among urologists. We evaluated whether a mini fellowship for robot assisted laparoscopic prostatectomy would enable postgraduate urologists to incorporate this new procedure into clinical practice. MATERIALS AND METHODS: From July 2003 to July 2006, 47 urologists participated in the robot assisted laparoscopic prostatectomy mini fellowship program. The 5-day course had a 1:2 faculty-to-attendee ratio. The curriculum included lectures, tutorials, surgical case observation, and inanimate, animate and cadaveric robotic skill training. Questionnaires assessing practice patterns 1, 2 and 3 years after the mini fellowship program were analyzed. RESULTS: One, 2 and 3 years after the program the response rate to the questionnaires was 89% (42 of 47 participants), 91% (32 of 35) and 88% (21 of 24), respectively. The percent of participants performing robot assisted laparoscopic prostatectomy in years 1 to 3 after the mini fellowship was 78% (33 of 42), 78% (25 of 32) and 86% (18 of 21), respectively. Among the surgeons performing the procedure there was a progressive increase in the number of cases each year with increasing time since the mini fellowship training. In the 3 attendees not performing the procedure 3 years after the mini fellowship training the reasons were lack of a robot, other partners performing it and a feeling of insufficient training to incorporate the procedure into clinical practice in 1 each. One, 2 and 3 years following the mini fellowship training program 83%, 84% and 90% of partnered attendees were performing robot assisted laparoscopic prostatectomy, while only 67%, 56% and 78% of solo attendees, respectively, were performing it at the same followup years. CONCLUSIONS: An intensive, dedicated 5-day educational course focused on learning robot assisted laparoscopic prostatectomy enabled most participants to successfully incorporate and maintain this procedure in clinical practice in the short term and long term.




“The urologic oncologist, robotic, and open radical prostatectomy: The need to look through the hype and propaganda and serve our patients.”

Ghavamian, R.

Urologic Oncology: Seminars and Original Investigations.




“The urologic oncologist, robotic, and open radical prostatectomy: The need to look through the hype and propaganda and serve our patients.”

Ghavamian, R. (2009).

Urol Oncol.




“Apical margins after robot-assisted radical prostatectomy: Does technique matter?”

Guru, K. A., A. E. Perlmutter, et al. (2009).

Journal of Endourology 23(1): 123-127.

Background and Purpose: The apex is the most common site of an involved surgical margin after robot-assisted radical prostatectomy. We assessed the impact of two surgical techniques for dorsal vein control on surgical margins rates. Patients and Methods: From August 2005 to January 2008, 480 patients underwent robot-assisted radical prostatectomy at Roswell Park Cancer Institute. The Roswell Park Cancer Institute Quality Assurance robotic prostatectomy database was reviewed to identify all patients with prostate cancer at the apex on final pathologic evaluation. The rate of positive apical margins was compared between two surgical techniques. Group 1 consisted of 145 patients who underwent apical dissection after cold incision of the dorsal venous complex (DVC) without previous suture ligation, and group 2 consisted of 158 patients who underwent suture ligation of the DVC before apical dissection. Results: Of 480 patients, 303 (63%) patients had prostate cancer in the apex. Age, body mass index, prostate-specific antigen level, and clinical stage were similar in both groups. The overall apical positive margin rate was 5%. Group 1 patients had an apical positive margin rate of 2%, while group 2 patients had a positive margin rate of 8% (P = 0.02). Mean operative blood loss estimated by the attending anesthesiologist was 331 mL and 268 mL in group 1 and group 2, respectively (P = 0.044). One patient in group 1 needed blood transfusion. Conclusions: Cold incision of the DVC before suture ligation reduces the rate of apical margin involvement during robot-assisted radical prostatectomy. © Mary Ann Liebert, Inc. 2009.




“Robotic ultrasound-guided prostate intervention device: system description and results from phantom studies.”

Ho, H. S., P. Mohan, et al. (2009).

Int J Med Robot 5(1): 51-8.

BACKGROUND: We introduce the first robotic ultrasound-guided prostate intervention device and evaluate its safety, accuracy and repeatability. METHODS: The robotic positioning system (RPS) determines a target’s x, y and z axes. It is situated with a biplane ultrasound probe on a mobile horizontal platform. The integrated software acquires ultrasound images for three-dimensional (3D) modelling, coordinates target planning and directs the RPS. RESULTS: The egg phantom evaluates the software’s safety and workflow protocol. Two random targets are planned in each quadrant and biopsy needles are inserted. All were within three separate eggs. Metal wire tips are targeted and their distances from the biopsy needle tips are measured. With 20 wires, < 1 mm accuracy is obtained. Repeatability is demonstrated when previous positions are returned to with similar accuracy. CONCLUSION: Our device demonstrates safety in a defined boundary with a repeatable accuracy of < 1 mm. It can be used for accurate prostate biopsy and treatment delivery.




“Preperitoneal Robotic Prostate Adenomectomy.”

John, H., C. Bucher, et al.


Objectives: To describe the surgical technique and evaluate the feasibility of robotic-assisted preperitoneal prostate adenomectomy for large benign adenomas in a pilot series. Methods: A total of 13 consecutive patients with a median age 70 years and body mass index of 26 kg/m2 in whom open adenomectomy was planned were included in this pilot study. The extraperitoneal robotic approach was standardized in all cases. The demographic, operative, and outcome measurements were analyzed. The conversion rate, total operative time, and blood loss served as the feasibility parameters. Results: The total operative time was 210 minutes (range 150-330). No open conversion was necessary. The blood loss was 500 mL (range 100-1100), with a 0% transfusion rate. Single-finger assistance improved the total operative time to 140 minutes (range 110-180; P = .007) and blood loss to 250 mL (range 200-350; P = .02). The specimen weight was 82 g (range 50-150). The indwelling catheters were removed after 6 days (range 3-15), and the patients returned to work after 13 days (range 8-17). After a median follow-up of 13 months (range 2-18), the patients had a median flow rate of 23 mL/s without any postvoid residual urine. Conclusions: The results of our study have shown that preperitoneal robotic transvesical prostate adenomectomy is a feasible and reproducible procedure. Additional series with larger patient cohorts and prostate adenomas are needed. © 2008 Elsevier Inc. All rights reserved.




“Preperitoneal Robotic Prostate Adenomectomy.”

John, H., C. Bucher, et al. (2009).


OBJECTIVES: To describe the surgical technique and evaluate the feasibility of robotic-assisted preperitoneal prostate adenomectomy for large benign adenomas in a pilot series. METHODS: A total of 13 consecutive patients with a median age 70 years and body mass index of 26 kg/m(2) in whom open adenomectomy was planned were included in this pilot study. The extraperitoneal robotic approach was standardized in all cases. The demographic, operative, and outcome measurements were analyzed. The conversion rate, total operative time, and blood loss served as the feasibility parameters. RESULTS: The total operative time was 210 minutes (range 150-330). No open conversion was necessary. The blood loss was 500 mL (range 100-1100), with a 0% transfusion rate. Single-finger assistance improved the total operative time to 140 minutes (range 110-180; P = .007) and blood loss to 250 mL (range 200-350; P = .02). The specimen weight was 82 g (range 50-150). The indwelling catheters were removed after 6 days (range 3-15), and the patients returned to work after 13 days (range 8-17). After a median follow-up of 13 months (range 2-18), the patients had a median flow rate of 23 mL/s without any postvoid residual urine. CONCLUSIONS: The results of our study have shown that preperitoneal robotic transvesical prostate adenomectomy is a feasible and reproducible procedure. Additional series with larger patient cohorts and prostate adenomas are needed.




“Radical prostatectomy for prostatic adenocarcinoma: A matched comparison of open retropubic and robot-assisted techniques.”

Krambeck, A. E., D. S. DiMarco, et al. (2009).

BJU International 103(4): 448-453.

OBJECTIVE: To assess the perioperative complications and early oncological results in a comparative study matching open radical retropubic (RRP) and robot-assisted radical prostatectomy (RARP) groups. PATIENTS AND METHODS: From August 2002 to December 2005 we identified 294 patients undergoing RARP for clinically localized prostate cancer. A comparison RRP group of 588 patients from the same period was matched 2:1 for surgical year, age, preoperative prostate-specific antigen level, clinical stage and biopsy Gleason grade. Perioperative complications were compared. Patients completed a standardized quality-of-life questionnaire. Pathological features were assessed and Kaplan-Meier estimates of biochemical progression-free survival (PFS) were compared. RESULTS: There was no significant difference in overall perioperative complications between the RARP and RRP groups (8.0% vs 4.8%, P = 0.064). Wound herniation was more common after RARP (1.0% vs none, P = 0.038), and development of bladder neck contracture was more common after RRP (1.2% vs 4.6%; P < 0.018). The hospital stay was less after RARP (29.3% vs 19.4%, P = 0.004, for a stay of 1 day). At the 1-year follow-up there was no significant difference in continence (RARP 91.8%, RRP 93.7%, P = 0.344) or potency (RARP 70.0%, RRP 62.8%, P = 0.081) rates. The biochemical PFS was no different between treatments at 3 years (RARP 92.4%, RRP 92.2%; P = 0.69). CONCLUSION: There was no significant difference in overall early complication, long-term continence or potency rates between the RARP and RRP techniques. Furthermore, early oncological outcomes were similar, with equivalent margin positivity and PFS between the groups. © 2008 The Authors.




“Robotic single-port transumbilical surgery in humans: initial report.”

Kaouk, J. H., R. K. Goel, et al. (2009).

BJU Int 103(3): 366-9.

OBJECTIVE: To describe our initial clinical experience of robotic single-port (RSP) surgery. PATIENTS AND METHODS: The da Vinci S robot (Intuitive, Sunnyvale, CA, USA) was used to perform radical prostatectomy (RP), dismembered pyeloplasty, and radical nephrectomy. A robot 12-mm scope and 5-mm robotic grasper were introduced through a multichannel single port (R-port, Advanced Surgical Concepts, Dublin, Ireland). An additional 5-mm or 8-mm robotic port was introduced through the same umbilical incision (2 cm) alongside the multichannel port and used to introduce robotic instruments. Vesico-urethral anastomosis and pelvi-ureteric anastomosis were successfully performed robotically using running intracorporeal suturing. RESULTS: All three RSP surgeries were performed through the single incision without adding extra umbilical ports or 2-mm instruments. For RP, the operative duration was 5 h and the estimated blood loss was 250 mL. The hospital stay was 36 h and the margins of resection were negative. For pyeloplasty, the operative duration was 4.5 h, and the hospital stay was 50 h. Right radical nephrectomy for a 5.5-cm renal cell carcinoma was performed in 2.5 h and the hospital stay was 48 h. The specimen was extracted intact within an entrapment bag through the umbilical incision. There were no intraoperative or postoperative complications. At 1 week after surgery, all patients had minimal pain with a visual analogue score of 0/10. CONCLUSIONS: Technical challenges of single-port surgery that may limit its widespread acceptance can be addressed by using robotic technology. Articulation of robotic instruments may render obsolete the long-held laparoscopic principles of triangulation especially for intracorporeal suturing. We report the initial series of robotic surgery through a single transumbilical incision.




“Impact of prostate median lobe anatomy on robotic-assisted laparoscopic prostatectomy.”

Meeks, J. J., L. Zhao, et al. (2009).

Urology 73(2): 323-7.

OBJECTIVES: Robotic-assisted laparoscopic prostatectomy (RALP) is becoming widely used for the management of prostate cancer. Although prostate size does not affect operative times for RALP, the effect of a large median prostate lobe has not been described. METHODS: One hundred fifty-four men underwent RALP by one surgeon between 2005 and 2007. Patients were categorized into 2 groups based on the presence or absence of a large median prostate lobe identified during RALP. The RALP was divided into sections from bladder mobilization to vesicourethral anastomosis. Operative times and outcomes were recorded prospectively. RESULTS: Of the 154 patients, 29 (18%) of the men had large median prostate lobes. Men with large median lobes were slightly older, but had similar prostate-specific antigen, body mass index, clinical and pathologic stage, biopsy and prostatectomy Gleason grade, tumor volumes, and surgical margin rate compared with men without median lobes. Yet, prostate weight, estimated blood loss, and hospital stay was significantly greater in men with large median lobes. The overall operative time for the RALP was greater in men with a large median lobe caused by an increased time required for posterior bladder neck and seminal vesicle dissection. There was no difference in complications such as urine leaks, bladder neck contractures, and migration of Hem-o-lok clips into the bladder. Continence at 3 and 6 months after RALP were not significantly different in men with large median lobes. CONCLUSIONS: Despite equivalent oncological outcomes, we demonstrate a significant increase in operative times among men with large median lobes.




“Anterior retraction of the prostate during robotic-assisted laparoscopic radical prostatectomy using the closure device.”

Murphy, D. G., D. Agarwal, et al. (2009).

BJU International 103(4): 558-562.

We have used this technique in over 700 cases of RALRP and have been pleased with its performance. The technique is quick and easy to adopt. It provides efficient anterior retraction of the prostate and frees the bedside surgeon or fourth arm of the robot to assist in other ways. We have noted no complications related to the use of this device in our experience to date. The Endo Close device is an inexpensive addition to the laparoscopic consumables cost of a RALRP and can also be used at the end of the case to assist in trocar site closure. Troubleshooting: It is important to introduce the Endo Close in the midline and close to the symphysis pubis to achieve the correct angle for catheter retraction. It can be difficult to choose the precise insertion point in the insufflated abdomen when the robotic cart is docked over the patient. Therefore we routinely mark an insertion point 1 cm above the symphysis pubis at the start of the case, before insufflating the abdomen. This point is easily identified even when the robot has been docked and allows insertion of the Endo Close at precisely the correct location. © 2009 The Authors.




“Operative Details and Oncological and Functional Outcome of Robotic-Assisted Laparoscopic Radical Prostatectomy: 400 Cases with a Minimum of 12 Months Follow-up{black small square}.”

Murphy, D. G., M. Kerger, et al.

European Urology.

Background: Robotic-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA) is increasingly used for the management of localised prostate cancer. Objective: We report the operative details and short-term oncological and functional outcome of the first 400 RALPs performed at our unit. Design, setting and participants: From December 2003 to August 2006, 400 consecutive patients underwent RALP at our institution. A prospective database was established to record the relevant details of all RALP cases. Surgical procedure: A six port transperitoneal approach using a 4-arm da Vinci® system was used to perform RALP. This database was reviewed to establish the operative details and oncological and functional outcome of all patients with a minimum of 12 months follow-up. Measurements: Perioperative characteristics and outcomes are reported. Functional outcome was assessed using continence and erectile function questionnaires. Biochemical recurrence (prostate-specific antigen (PSA) ?0.2 ng/mL) is used as a surrogate for cancer control. Results and limitations: The mean age ± standard deviation (SD) was 60.2 ± 6 years. Median PSA level was 7.0 (interquartile range (IQR) 5.3-9.6) ng/mL. The mean operating time ± SD was 186 ± 49 mins. The complication rate was 15.75% comprising Clavien grade I-II and Clavien grade III complications in 10.5% and 5.25% of patients respectively. The overall positive surgical margin rate was 19.2% with T2 and T3 positive margin rates of 9.6% and 42.3% respectively. The biochemical recurrence-free survival was 86.6% at a median follow-up of 22 (IQR = 15-30) months. At 12 months follow-up, 91.4% of patients were pad-free or used a security liner. Of those men previously potent (defined as Sexual Health Inventory for Men [SHIM] score ?21) who underwent nerve-sparing RALP, 62% were potent at 12 months. Conclusions: The safety and feasibility of RALP has already been established. Our initial experience with this procedure shows promising short-term outcomes. © 2008 European Association of Urology.




“Does 3-Dimensional (3-D) visualization improve the quality of assistance during robotic radical prostatectomy?”

Ramanathan, R., J. I. M. Salamanca, et al. (2009).

World Journal of Urology 27(1): 95-99.

Objective: 3-Dimensional (3-D) visualization by the surgeon is considered to be one of the major advantages of robotic prostatectomy. We undertook this study to see if passing on this technology to the surgical assistants would improve the efficiency of their assistance. Materials and methods: The study was conducted in consecutive patients undergoing robotic radical prostatectomy by the same team, in one month at our center. A 3-D head mounted device (HMD) was used by the left and/ or right assistant. Video recording from these patients were studied by a blinded observer with prior training in laparoscopic surgery for the efficiency of laparoscopic moves by the two assistants. These moves were scored on a point scoring system from 0 to 100 with 100 signifying the best possible performance. Results: After exclusions, 26 videos were available for review. Each patient had a right and left-sided assistant. The right-sided assistant had prior experience in Laparoscopic Urology, and the left-sided assistant had a relatively limited laparoscopic experience. The mean scores for the left assistant improved from 76.3 to 84.6 with the use of 3-D visualization (p < 0.002), while the improvement for the right assistant was from 84.1 to 86.9 (NS). Conclusions: The use of 3-D visualization possibly improves the efficiency of assistance during robotic radical prostatectomies, for the assistant with limited experience in laparoscopic surgery. Because of the high-quality 3-D vision provided, these HMDs have the potential to be used as teaching aids in the robotic lab. © Springer-Verlag 2008.




“Management of an enlarged median lobe with ureteral orifices at the margin of bladder neck during robotic-assisted laparoscopic prostatectomy.”

Rehman, J., B. Chughtai, et al. (2009).

Can J Urol 16(1): 4490-4.

OBJECTIVE: To present our technique for the management of an enlarged median lobe when the ureteral orifices are close to the bladder neck during robotic-assisted radical prostatectomy. MATERIALS AND METHODS: From January 2005 to January 2007, we performed over 600 robotic assisted radical prostatectomies. We had 63 patients (10%) with enlarged medium lobes. Of these patients, two (5.7%) had their ureteral orifices in close proximity to the bladder neck. An additional patient, without a median lobe, had his orifices very close to the bladder neck. To aid in the management of their median lobes, all three patients had bilateral placement of ureteral catheters manually by the daVinci robot. We present our technique of robotic-assisted catheter insertion during robotic prostatectomy to protect the ureteral orifice from damage, precluding the use of a cystoscope. RESULTS: All three patients, underwent successful robotic-assisted radical prostatectomy (RALP) aided by intraoperative placement of either a double J ureteral catheters or open ended ureteral catheters that were removed after completion of the anastamosis. All three had normal cystograms before Foley catheter removal. All three patients were continent with follow up PSAs < 0.1. The presence of a median lobe slightly increased the operative time required for bladder neck dissection or anastomosis (including reconstruction). There was no difference in complications such as urine leaks and bladder neck contractures. Continence after RALP was not significantly different in men with large median lobes. CONCLUSION: Management of ureteral orifices that are too close to the bladder neck with or without large medium lobes can be successfully performed with the uses of ureteral catheters placed robotically with the da Vinci robot. The presence of a median lobe does not alter outcomes in patients who undergo robot-assisted laparoscopic prostatectomy.




“Role of Extent of Fascia Preservation and Erectile Function After Robot-assisted Laparoscopic Prostatectomy.”

van der Poel, H. G. and W. D. Blok (2009).


OBJECTIVES: To test a simple intraoperative scoring system for the circumferential extent of fascia preservation (FP) for the prediction of postoperative erectile function. With the advent of robotic and endoscopic surgery for prostate cancer, more extensive FP has emerged as a method to improve postoperative erectile function. METHODS: A total of 107 consecutive cases with normal preoperative erectile function were treated using robot-assisted laparoscopic prostatectomy for localized prostate cancer. The erectile, sexual, and global quality of life outcomes using the European Organization for Research and Treatment and Cancer Quality of Life questionnaire-C30 and prostate cancer-specific 25-item questionnaire were assessed at 6 months postoperatively. RESULTS: At 6 months postoperatively, 57 men (53%) reported no or minimal effects on erectile function with or without the use of a phosphodiesterase type 5 inhibitor. The patient age at surgery, prostate size, and FP score were associated with erectile function at 6 months postoperatively. The mean FP score was 9.2 +/- 2.8 and 4.7 +/- 2.4 for patients without and with erectile dysfunction postoperatively, respectively. On multivariate analysis, the FP score and patient age at surgery were the best predictors of postoperative erectile function. No correlation between the FP score and positive surgical resection margin rate was observed. A greater FP score predicted for greater questionnaire-based libido, sexual activity, and sexual function scores. CONCLUSIONS: A scoring system for the extent of circumferential FP during prostatectomy is a stronger predictor of postoperative erectile function recovery than is laterality (bilateral or unilateral) or fascial depth (interfascial or intrafascial). More ventral FP significantly contributed to postoperative erectile function recovery.




“Robotic radical prostatectomy in overweight and obese patients: oncological and validated-functional outcomes.”

Wiltz, A. L., S. Shikanov, et al. (2009).

Urology 73(2): 316-22.

OBJECTIVES: To determine the impact of body mass index (BMI) on perioperative functional and oncological outcomes in patients undergoing robotic laparoscopic radical prostatectomy (RLRP) when stratified by BMI. METHODS: Data were collected prospectively for 945 consecutive patients undergoing RLRP. Patients were evaluated with the UCLA-PCI-SF36v2 validated-quality-of-life questionnaire preoperatively and postoperatively to 24 months. Patients were stratified by BMI as normal weight (BMI < 25 kg/m(2)), overweight (BMI = 25 to < 30 kg/m(2)) and obese (BMI > or = 30 kg/m(2)) for outcomes analysis. RESULTS: Preoperatively, obese men had a significantly greater percentage of medical comorbidities (P < .01) as well as a baseline erectile dysfunction (lower mean baseline Sexual Health Inventory for Men score [P = .01] and UCLA-PCI-SF36v2 sexual function domain scores [P = .01]). Mean operative time was significantly longer in obese patients when compared with normal and overweight men (234 minutes vs 217 minutes vs 214 minutes; P = .0003). Although overall complication rates were comparable between groups, a greater incidence of case abortion caused by pneumoperitoneal pressure with excessive airway pressures was noted in obese men. Urinary continence and potency outcomes were significantly lower for obese men at both 12 and 24 months (all P < .05). CONCLUSIONS: In this series, obese men experienced a longer operative time, particularly during the initial robotic experience. As such, surgeons early in their RLRP learning curve should proceed cautiously with surgery in these technically more difficult patients or reserve such cases until the learning curve has been surmounted. These details, including inferior urinary and sexual outcomes, should be discussed with obese patients during preoperative counseling.




“Robotic pediatric urology.”

Casale, P. (2009).

Curr Urol Rep 10(2): 115-8.

Robotic-assisted minimally invasive surgery is penetrating pediatric urology. The freedom afforded by the “surgical actuators” has led to the expanding adoption of robotics, and it is unlikely that much of laparoscopy will not trend toward some iteration of robotic influence. The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA) provides delicate telemanipulation, coalesced with three-dimensional visualization and superior magnification. It has bridged the gap between laparoscopy and open surgery. Nonetheless, a confident understanding of pure laparoscopy is paramount in the event that mechanical malfunction is experienced. Robotic pediatric urologic procedures such as pyeloplasty, ureteral reimplantation, abdominal testis surgery, and partial or total nephrectomy with or without ureteral stump removal are routinely performed at select centers offering robotic expertise. Complex reconstructive surgeries such as appendicovesicostomy, antegrade continent enema creation, and augmentation cystoplasty can be performed but are still in their infancy.