Abstrakt Urologie Únor 2011

“Robotic bladder diverticulectomy: Technique and surgical outcomes.”

Altunrende, F., R. Autorino, et al. (2011).

International Journal of Urology.


Objectives: Indications for surgical treatment of bladder diverticula include tumor, lower urinary tract symptoms refractory to medical treatment, renal dysfunction or recurrent urinary tract infections. We describe the technique and report the outcomes of robotic bladder diverticulectomy at our institution. Methods: A chart review of patients who underwent robotic bladder diverticulectomy at our institution from 2007 to 2010 was carried out. Indications for the procedure were: lower urinary tract symptoms (LUTS) not responding to medical treatment (2 patients), ureteral obstruction (1 patient), tumor arising in a diverticulum (2 patients) and diverticulum secondary to neurogenic bladder (1 patient). One patient also had renal dysfunction associated with ureteral insertion into the diverticulum and therefore underwent ipsilateral ureteroneocystostomy. Other additional procedures included transurethral resection of the prostate (1 patient) and bilateral pelvic lymph node dissection (1 patient). Perioperative and postoperative outcomes were analyzed. Results: Six patients (median age 61.5 years, range 19-75) underwent da Vinci diverticulectomy using a transperitoneal approach without the need for open conversion. Median operative time was 232 min (135-360 min.). Median estimated blood loss was 100 mL (50-150 mL). The Foley catheter was removed after a negative cystogram and median time to catheter removal was 7 days (7-12 days). Median hospital stay was 3 days (2-5 days). The only complication was a urinary tract infection managed with antibiotics. Conclusions: Robotic surgery represents a reasonable minimally invasive treatment option for resection of bladder diverticula when indicated.




“Feasibility and Outcomes of Robotic-assisted Laparoscopic Radical Cystectomy for Bladder Cancer in Older Patients.”

Coward, R. M., A. Smith, et al. (2011).



OBJECTIVES: To report our maturing experience with robotic radical cystectomy as applied to an older patient population with regard to perioperative measures and pathologic outcomes. A robotic approach to radical cystectomy for bladder cancer have recently been described, but its application in an older patient population, which is often the case in bladder cancer and cystectomy, has not yet been assessed. METHODS: A total of 119 patients underwent robotic cystectomy and extracorporeal urinary diversion at our institution from January 2006 through October 2009 for clinically localized bladder cancer. Owing to the patient selection early in the present series, the first 20 cases were excluded. The clinical characteristics, operative outcomes, and pathologic results of the consecutive cases were categorized by age (younger, <70 years vs older, age >/=70 years). RESULTS: The outcomes of the 61 younger and 38 older patients, including 7 patients >80 years old, were assessed. The younger versus older patients had a lower American Society of Anesthesiologists score (2.6 vs 3.0; P < .001), greater body mass index (28.2 vs 26.1; P = .008), and longer operating room time (4.8 vs 4.4 hours; P = .015). No differences were observed between the 2 groups in blood loss, time to discharge, or complication rate. Also, no significant differences were found in the surgical pathologic findings, including the organ-confined rate (62% vs 71%) and lymph node yield (19.5 vs 18.1). CONCLUSIONS: Older patients do not appear to have any significant differences or compromises with regard to the perioperative and pathologic outcomes after robotic radical cystectomy. Thus, robotic radical cystectomy appears to be an appropriate surgical option for older patients.




“Analysis of early complications of robotic-assisted radical cystectomy using a standardized reporting system.”

Khan, M. S., O. Elhage, et al. (2011).

Urology 77(2): 357-362.


Objective: To analyze the early complications of robotic-assisted laparoscopic radical cystectomy (RARC) with extracorporeal ileal conduit or orthotopic (Studer) bladder reconstruction using the Clavien Classification, the management of these complications, and possible preventive measures. Materials and Methods: Detailed data on all patients undergoing RARC were recorded prospectively on an encrypted database, including intraoperative or postoperative complications within 90 days of surgery. Outcome data during follow-up of up to 4 years was also collected prospectively. Results: A total of 50 patients (M:F 44:6) underwent RARC and extracorporeal ileal conduit urinary diversion (n = 45) or orthotopic bladder reconstruction (n = 5) between 2004 and 2008. The overall perioperative complication rate was 17 of 50 (34%), including 3 (6%) Clavien I, 9 (18%) Clavien II, and 5 (10%) Clavien III. Final histology showed 9 (18%) patients had no residual disease pT0, 7 (14%) pTa, 11 (22%) pT1, 9 (18%) pT2, 11 (22%) pT3, and 3 (6%) pT4. Conclusion: Radical cystectomy remains a complex and morbid procedure with significant complication rate regardless of surgical approach. Using the Clavien reporting system, we identified early complications in 34% of patients, of which five required a significant intervention. Use of this standardized reporting system has allowed us to stratify complications after RARC, allowing easy comparison to other techniques and targeting further reductions in the future. © 2011 Elsevier Inc.




“Comment to: “Robotic-assisted laparoscopic radical cystectomy: evaluation of functional and oncological results”.”

Palou, J. (2011).

Actas Urologicas Espanolas.




“Robotic-Assisted Laparoscopic Radical Cystectomy: Evaluation of Functional and Oncological Results.”

Treiyer, A., M. Saar, et al. (2011).

Actas Urologicas Espanolas.


PURPOSE: radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. We report our experience with 84 consecutive cases of robotic assisted laparoscopic radical cystectomy with regard to perioperative results, pathological outcomes and surgical complications. MATERIALS AND METHODS: a total of 84 consecutive patients (70 male and 14 female) underwent robotic radical cystectomy and urinary diversion at our institution from January 2007 to August 2010 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes and complication rate. RESULTS: mean age of this cohort was 65.5 years (range 28 to 82). Of the patients 62 underwent ileal conduit diversion, 22 received a neobladder. Mean operating room time for all patients was 261min. (range: 243-618min.) and mean surgical blood loss was 298ml (range: 50-2000ml). 29% of the cases were pT1 or less disease, 38% were pT2, 26% and 7% were pT3 and T4 disease respectively, 15% were node positive. Mean number of lymph nodes removed was 15 (range 1 to 33). In 2 cases (2.4%) there was a positive surgical margin. Mean days to flatus were 2.12, bowel movement 2.87 and discharge home 17.7 (range: 10-33). There were 45 postoperative complications with 11.9% having a major complication (Clavien grade 3 or higher). At a mean followup of 16.7 months 10 patients (11%) had disease recurrence and 2 died of disease. CONCLUSIONS: our experience with robotic radical cystectomy for the treatment of bladder cancer suggests that in proper hands this procedure provides acceptable surgical and pathological outcomes.




“Surgical management of renal cystic disease.”

Agarwal, M. M. and A. K. Hemal (2011).

Current Urology Reports 12(1): 3-10.


The kidney is one of the most common sites for cyst in the body (prevalence about 5%). Symptomatic or incidental cyst needs to be characterized further based on Bosniak classification as simple (Bosniak type I & II) or complex (Bosniak type III & IV) cysts with respect to risk of malignancy or other effects on the kidney. The management of simple cysts is entirely for its symptoms or complications (eg, hemorrhage, infection, hydronephrosis, and hypertension). Percutaneous aspiration alone or with sclerotherapy often is the first-line treatment. Surgical decortication generally is reserved for recurrent or very large symptomatic cysts. Laparoscopic surgery is highly efficacious and is associated with high satisfaction rates with minimal morbidity. Retroperitoneal approach is generally preferred, especially in infected or hydatid renal cyst to avoid spillage or contamination of virgin peritoneal cavity. Cyst decortication seems to be an appropriate indication for newer-emerging single-port laparoscopic approaches such as natural orifice transluminal endoscopic surgery, single-incision laparoscopic surgery, or laparoendoscopic single-site surgery. Where available, robot-assisted surgical management can supplant pure laparoscopic management for complex cysts, hydatid cyst, peripelvic cyst, and autosomal dominant polycystic kidney disease without any outstanding benefits, but with added cost, when robot is used. © 2010 Springer Science+Business Media, LLC.




“Robot-assisted partial nephrectomy: current status, techniques, and future directions.”

Babbar, P. and A. K. Hemal (2011).

International Urology and Nephrology.


Open partial nephrectomy for the treatment of small renal masses (SRMs) concerning for renal cell carcinoma has been increasingly utilized with the increased incidental detection of SRMs and the growing recognition of the benefits of renal preservation. Laparoscopic partial nephrectomy (LPN) is a minimally invasive technique that achieves comparable oncologic and improved morbidity outcomes when compared to the open procedure. However, LPN is a technically demanding procedure resulting in a long learning curve and a lack of widespread adoption. Robot-assisted partial nephrectomy (RAPN) overcomes many of the technical hurdles of the LPN and is now coming to the forefront for the minimally invasive surgical management of SRMs. To date, the short-term oncologic outcomes of RAPN have been comparable to the open operation while providing the improved morbidity outcomes of LPN. Although encouraging, we await the long-term oncologic results of this new and promising procedure. The current bottleneck is an issue of cost and reliance on a patient-side surgeon. Future developments in instrumentation, newer robots, cost reduction, more streamlined training, increased robotic experience, and adoption by more centers will lead to greater benefit for patients with SRMs requiring nephron-sparing surgery. This review will discuss techniques for RAPN and then delve into the current status of RAPN using parameters such as warm ischemia time, blood loss, hospital stay, oncological outcomes, complications, learning curve, and quality of life. There will be an exploration of potential disadvantages associated with RAPN followed by a look at evolving techniques in regard to this groundbreaking procedure.




“Robot-assisted laparoscopic partial nephrectomy for tumors greater than 4 cm and high nephrometry score: Feasibility, renal functional, and oncological outcomes with minimum 1 year follow-up.”

Gupta, G. N., R. Boris, et al. (2010).

Urologic Oncology: Seminars and Original Investigations.


Objectives: Minimally invasive robotic assistance is being increasingly utilized to treat larger complex renal masses. We report on the technical feasibility and renal functional and oncologic outcomes with minimum 1 year follow-up of robot-assisted laparoscopic partial nephrectomy (RALPN) for tumors greater than 4 cm. Materials and methods: The urologic oncology database was queried to identify patients treated with RALPN for tumors greater than 4 cm and a minimum follow-up of 12 months. We identified 19 RALPN on 17 patients treated between June 2007 and July 2009. Two patients underwent staged bilateral RALPN. Demographic, operative, and pathologic data were collected. Renal function was assessed by serum creatinine levels, estimated glomerular filtration rate, and nuclear renal scans assessed at baseline, 3, and 12 months postoperatively. All tumors were assigned R.E.N.A.L. nephrometry scores (http://www.nephrometry.com). Results: The median nephrometry score for the largest tumor from each kidney was 9 (range 6-11) while the median size was 5 cm (range 4.1-15). Three of 19 cases (16%) required intraoperative conversion to open partial nephrectomy. No renal units were lost. There were no statistically significant differences between preoperative and postoperative creatinine and eGFR. A statistically significant decline of ipsilateral renal scan function (49% vs. 46.5%, P = 0.006) was observed at 3 months and at 12 mo postoperatively (49% vs. 45.5%, P = 0.014). None of the patients had evidence of recurrence or metastatic disease at a median follow-up of 22 months (range 12-36). Conclusions: RALPN is feasible for renal tumors greater than 4 cm with moderate or high nephrometry scores. Although there was a modest decline in renal function of the operated unit, RALPN may afford the ability resect challenging tumors requiring complex renal reconstruction. The renal functional and oncologic outcomes are promising at a median follow-up of 22 months, but longer follow-up is required.




“Long-Term Experience and Outcomes of Robotic Assisted Laparoscopic Pyeloplasty in Children and Young Adults.”

Minnillo, B. J., J. A. Cruz, et al. (2011).

Journal of Urology.


PURPOSE: Laparoscopic pyeloplasty is one of the more common robotic assisted procedures performed in children. However, data regarding long-term experience and clinical outcomes for this procedure are limited. We evaluated the long-term outcomes in a large series of patients undergoing robotic assisted laparoscopic pyeloplasty at a teaching institution, and the effect of a collaborative program between the robotic surgeons, surgical nurses and anesthesiologists on overall operative time. MATERIALS AND METHODS: We retrospectively reviewed 155 patients who underwent robotic assisted laparoscopic pyeloplasty between 2002 and 2009. Operative data, including surgical approach, type of procedure, total and specific operative times and placement of ureteral stents, were determined. Postoperative outcome measurements, including duration of hospital stay, duration of Foley catheter drainage, radiological findings and any subsequent complications, were assessed. RESULTS: Mean operative time and length of hospitalization decreased significantly by the end of the study. At a mean followup of 31.7 months the primary success rate was 96% (hydronephrosis was improved in 85% of patients and stable in 11%). The complication rate was 11%, and recurrent obstruction requiring redo robotic assisted laparoscopic pyeloplasty or open pyeloplasty developed in 3% of patients. Success rate and complication rate were unchanged during the study period. CONCLUSIONS: This study confirms that even within the confines of a pediatric urology training program successful collaboration between robotic surgeons, surgical nurses and anesthesiologists can lead to shorter operative times and hospital stays. Long-term surgical success and complication rates were comparable to open surgery.




“Validation of the preoperative aspects and dimensions used for an anatomical (PADUA) score in a robot-assisted partial nephrectomy series.”

Mottrie, A., P. Schatteman, et al. (2011).

World Journal of Urology: 1-6.


Objectives: PADUA score is a standardized anatomical classification of renal tumors proposed with the aim to objectivize the decision-making process of any urologist evaluating kidney tumors potentially suitable for nephron-sparing surgery. The system was proposed in a series of patients treated with open partial nephrectomy (PN) and was recently validated in a series of patients treated with either open or laparoscopic PN. The purpose of the present study was to validate the PADUA score in a series of consecutive patients who underwent robot-assisted PN (RPN). Methods: We evaluated retrospectively all the MRI or CT images of 62 consecutive patients who underwent RPN for renal tumors at a nonacademic teaching institution by a single surgeon between September 2006 and November 2009. Results: PADUA score (6-7 vs. 8-11) was correlated with warm ischemia time (WIT) (P = 0.002), console time (P = 0.001), blood loss (P = 0.009), percentage of pelvicaliceal repair (P = 0.002), and overall complications (P = 0.02). PADUA score was the only variable able to predict the risk of the overall complications (P = 0.02). PADUA score turned out to be an independent predictor of WIT >20 min in multivariable analysis (OR 5.4; P = 0.002), once adjusted for surgeon’s experience Finally, PADUA score was the only independent predictor of the need for pelvicaliceal repair (OR 3.7; P = 0.006). Conclusions: PADUA classification was an effective tool to predict WIT and risk of perioperative complications also in patients who underwent RPN. This classification must be considered useful to improve patients counseling and selection for RPN. © 2011 Springer-Verlag.




“Is robot-assisted partial nephrectomy already mature for challenging cases?”

Paparel, P., T. Bessede, et al. (2011).

European Urology 59(3): 331-332.




“Computer-assisted robotic renal surgery.”

Petros, F. G. and C. G. Rogers (2010).

Therapeutic Advances in Urology 2(3): 127-132.


Computer-assisted robotic renal surgery (CARRS) is a minimally invasive surgical treatment option for renal tumors. We review the literature regarding techniques and outcomes and the potential advantages of CARRS. We retrospectively reviewed the literature regarding techniques and outcomes of CARRS, with specific analysis on robotic radical nephrectomy (RRN) and robotic partial nephrectomy (RPN). Multiple papers on RRN and RPN were found where the techniques were performed with either a transperitoneal or a retroperitoneal approach. Preliminary outcomes with RRN and RPN were at least comparable to those of a laparoscopic approach, with some parameters of RPN improved over the laparoscopic approach (warm ischemia time, length of hospital stay and estimated blood loss). CARRS is an emerging field with preliminary outcomes at least comparable to the laparoscopic approach. Large prospective, randomized trials are needed to assess the benefit of CARRS compared with current methods. © The Author(s), 2010.




“Outcomes of Robotic Partial Nephrectomy for Renal Masses With Nephrometry Score of >/=7.” White, M. A., G. P. Haber, et al. (2011).



OBJECTIVES: To evaluate the safety and feasibility of robotic partial nephrectomy for patients with complex renal masses. METHODS: We reviewed the data for 164 consecutive patients who had undergone transperitoneal robotic partial nephrectomy at a tertiary care center from February 2007 to June 2010. Of the 112 patients who had available imaging studies to review, 67 were identified and classified as having a moderately or highly complex renal mass according to the R.E.N.A.L. nephrometry score (>/=7) (tumor size-[R]adius, location and depth-[E]xophytic or endophytic; nearness to the renal sinus fat or collecting system [N]; anterior or posterior position [A], and polar vs non-polar location [L]). The preoperative, perioperative, pathologic, and functional outcomes data were analyzed. RESULTS: The median body mass index was 29.6 kg/m(2) (range 19.9-44.8). Of the 67 patients, 32 were men and 35 were women, with 32 right-sided masses and 35 left-sided masses. The median tumor size was 3.7 cm (range 1.2-11), and the median operative time was 180 minutes (range 150-180). The median estimated blood loss was 200 mL (range 100-375), and the warm ischemia time was 19.0 minutes (range 15-26). The median hospital stay was 3.0 days (range 3-4). The estimated glomerular filtration rate was calculated at a median decrease of 11.1 mL/min/1.73 m(2) (range 9-1.3). According to the Clavien-Dindo classification of surgical complications, 2 grade 1, 12 grade 2, and 1 grade 3 complication occurred. All margins were pathologically negative, except for 1, and, after a mean follow-up of 10 months, no recurrences had developed. CONCLUSIONS: Robotic partial nephrectomy is a safe and feasible option for moderately or highly complex renal masses determined by the R.E.N.A.L. nephrometry score. The warm ischemia time, blood loss, and complications were increased with highly complex masses.




“Robotic Ureterolysis for Relief of Ureteral Obstruction from Retroperitoneal Fibrosis.”

Keehn, A. Y., P. W. Mufarrij, et al. (2011).



Objective: To review our experience with robotic surgery for the management of retroperitoneal fibrosis (RPF) with ureteral obstruction. Ureteral obstruction is common in retroperitoneal fibrosis RPF. Methods: Since April 2006, 21 patients have presented to our institution with ureteral obstruction, apparently from RPF. All underwent robotic biopsy. If frozen pathology reveals malignancy, is equivocal, and/or the fibrotic reaction is extensive, we stent the obstructed side(s) and await final pathology. If RPF is confirmed, medical therapy is initiated to relieve obstruction; failures receive salvage ureterolysis. Lymphomas are referred to medical oncology. If frozen pathology demonstrates RPF, immediate ureterolysis is performed, if technically feasible. Ureterolysis is not performed for uninvolved contralateral systems. We reviewed data with institutional review board approval. Results: Of 21 patients, 3 were diagnosed with lymphoma and 18 with RPF. Seventeen patients (21 renal units) with RPF received robotic ureterolysis (11 primary, 6 salvage); the other patient died of trauma before intervention. The only perioperative complication, an enterocutaneous fistula, required bowel resection. Three patients required a secondary procedure to relieve obstruction. At a mean follow-up of 20.5 months, no renal unit has evidence of obstruction, and all patients have improved or resolved symptoms. Furthermore, none of the 13 patients who underwent a unilateral ureterolysis have had disease progression to the contralateral side. Conclusions: Robotic ureterolysis can be performed with minimal morbidity and provides durable success rates for relief of symptoms and obstruction in RPF. Biopsy remains integral to ruling out lymphoma. Empiric contralateral ureterolysis may not be necessary. © 2011 Elsevier Inc. All rights reserved.




“Multiple metachronous fibroepithelial polyps in children.”

Kojima, Y., S. M. Lambert, et al. (2011).

Journal of Urology 185(3): 1053-1057.


PURPOSE: We present our experience with a new phenotype of fibroepithelial polyps recurring in the urinary tract in children after robotic or laparoscopic pyeloplasty, and discuss the most appropriate treatment for these multiple metachronous neoplasms. MATERIALS AND METHODS: At our institution 14 children had fibroepithelial polyps as the cause of ureteropelvic junction obstruction at pyeloplasty. Of the patients 12 had at least 1 additional polyp in the ureter, necessitating concomitant ureteroscopy at either robotic or laparoscopic pyeloplasty. Of these 12 patients 9 had followup of at least 1 year. RESULTS: In 6 patients with at least 1 year of followup neoplasms were seen on retrograde pyelography and ureteroscopy that were not present on ureteroscopy at pyeloplasty. At 6 months after stent removal following the first recurrence 2 patients (33%) showed a second recurrence on imaging at a different location in the upper tract requiring laser ablation. One of these patients had a third recurrence that required further intervention before all were disease-free. No major intraoperative or preoperative complications developed. CONCLUSIONS: We should always consider the possibility of recurrent fibroepithelial polyps in children with ureteropelvic junction obstruction, and recommend routine retrograde pyelography and ureteroscopy at stent removal after laparoscopic or robotic pyeloplasty. Although ureteroscopic management seems to be the most appropriate modality in children with multiple metachronous fibroepithelial polyps, larger studies are needed.




“Multimodality laparoscopic liver resection for hepatic malignancy – from conventional total laparoscopic approach to robot-assisted laparoscopic approach.”

Lai Eric, C. H., C. N. Tang, et al. (2011).

International Journal of Surgery.


INTRODUCTION: Laparoscopic liver resection can either be total laparoscopic or hand-assisted laparoscopic approach. The recent introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery. It was developed to overcome the disadvantages of conventional laparoscopic surgery. The role of robotic system in laparoscopic surgery was not well evaluated yet. The aim of this cohort study was to evaluate the outcome of multimodality approach of laparoscopic liver resection for hepatic malignancy METHODS: From January 1998 to August 2010, all patients with hepatic malignancy underwent laparoscopic liver resection were included. A prospectively collected data was analyzed retrospectively. RESULTS: During the study period, a total of 56 patients with hepatic malignancies (hepatocellular carcinoma, HCC, n=42; colorectal liver metastases, CLM, n=14) underwent laparoscopic liver resection in our surgical unit. The majority of cases were performed by hand-assisted laparoscopic approach, n=31 (55.3%) and the remainder were with total laparoscopic approach, n=10 (17.9%) and robot-assisted laparoscopic approach, n=15 (26.8%). The median operation time was 150 minutes (range, 75-307 minutes). The median blood loss during surgery was 175 ml (range, 5-2000 ml). Two patients (3.6%) needed open conversion and one patient (1.8%) needed to be converted to hand-assisted laparoscopic approach. The morbidity rate was 14.3%. There was no procedure-related death. 89.3% of patients had R0 resection and 10.7% of patients had R1 resection. The median hospital stay was 6.5 days (range, 2-13 days). The 1-year, 3-year, and 5-year disease-free survival rates for HCC were 85%, 47%, and 38%, respectively. The 1-year, 3-year, and 5-year overall survival rates for HCC were 96%, 67%, and 52%, respectively. The 1-year, and 3-year disease-free survival rates for CLM were 92% and 72%. The 1-year, and 3-year overall survival rates for CLM were 100% and 88%, respectively. CONCLUSIONS: Multimodality approach of laparoscopic liver resection of hepatic malignancy was feasible, and safe in selected patients. It was associated with a low complications rate. The mid-term and long-term survival outcome was favorable also.




“Total intracorporeal robot-assisted laparoscopic ileal conduit (Bricker) urinary diversion: technique and outcomes.”

Rehman, J., M. N. Sangalli, et al. (2011).

Can J Urol 18(1): 5548-5556.


OBJECTIVE: Several recent preliminary reports have demonstrated that Robot-Assisted Cystectomy with total intracorporeal Ileal Conduit (RACIC) is a feasible option over the open technique. We report our stepwise surgical procedure of robotic total intracorporeal ileal conduit urinary diversion, technical consideration, development, refinements and initial experience. Only the ileal conduit urinary diversion is described with no emphasis on the cystectomy’s steps. METHODS: Between February 2008 and September 2009, nine patients underwent RACIC for muscle invasive transitional cell carcinoma (TCC). The entire procedure, including radical cystoprostatectomy, extended pelvic node dissection (ePLND), ileal conduit urinary diversion (Bricker) including isolation of the ileal loop (20 cm ileal segment) 15 cm away from the ileocecal junction, restoration of bowel continuity with stapled side-to-side ileo-ileal anastomosis, retroperitoneal transfer of the left ureter to the right side, and bilateral stented (8 F feeding tube) ileo-ureteral anastomoses in a Wallace faction were all performed exclusively intracorporeally using the da Vinci Si surgical robot and finally the conduit stoma was fashioned. RESULTS: The RACIC was technically successful in all nine patients (three females and six males. Mean age 74.1; 57 to 87) without open conversion. The mean operative time including extended pelvic lymphadenectomy and urinary diversion was 346.2 minutes (210 to 480). Mean operative time of diversion is 72 minutes (52-113) mean estimated blood loss 258 mL (200 to 500) and the median hospital stay were 14 days (10 to 27). In all three female patients, the specimen was extracted through the vagina. There were no intraoperative complications and only one major postoperative complication: one postoperative iatrogenous necrosis of the ileal conduit caused by uncareful retraction of the organ bag and thereby probably injuring the conduit pedicle, as the ileal conduit was well vascularised at the end of the operation, requiring an open revision (in male patient extracted through the suprapubic incision). A clear liquid diet was started on the third postoperative day. All patients returned to normal activity within 2 weeks (from date of surgery). Postoperative renal function was normal with mean postoperative creatine 0.99 mg/dL) and excretory urography revealed unobstructed upper tracts in all cases. CONCLUSION: Robot-assisted radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion for the treatment of high risk or invasive bladder cancer with urinary diversion is technically feasible. The robotic system aids in performing a meticulous dissection and all operative steps of the open procedure are replicated precisely while adhering to the sound oncologic principles of traditional radical cystectomy. Robotics brings an unprecedented control of surgical instruments, shorten the learning curve, and allow open surgeons to apply more easily their technical skill in a minimal invasive fashion. Robotic cystectomy with total intracorporeal ileal conduit urinary diversion offers operative and perioperative benefits and functional outcome. In our hands results comparable to open experience with further reduced perioperative morbidity, early recovery, resumption of normal activities, excellent cosmesis and increased quality of life (QOL). In addition, minimal blood loss, fluid shifts, and electrolyte loss considerably reduce systemic and cardiovascular stress in these older groups of patients.




“Continence Outcomes in Patients Undergoing Robotic Assisted Laparoscopic Mitrofanoff Appendicovesicostomy.”

Wille, M. A., G. P. Zagaja, et al. (2011).

Journal of Urology.


PURPOSE: Continent catheterizable channels for emptying the bladder are typically performed via an open surgical approach. We present our surgical approach and initial outcomes with specific attention to continence for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy formation. MATERIALS AND METHODS: Between February 2008 and April 2010, 13 patients were considered for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy and 11 underwent the procedure (2 open conversions). Five patients underwent enterocystoplasty with appendicovesicostomy and 6 underwent isolated appendicovesicostomy. The appendicovesicostomy anastomosis was performed on the anterior (without augmentation) or posterior (with augmentation) bladder wall and the stoma was brought to the umbilical site or right lower quadrant. Detrusor backing (4 cm) was ensured except in 1 patient (number 5). RESULTS: Mean patient age at surgery was 10.4 years (range 5 to 14). Mean estimated blood loss was 61.8 cc. Mean operative time for isolated appendicovesicostomy was 347 minutes and there were no intraoperative complications. Incontinence through the stoma developed in 1 patient with inadequate detrusor backing (less than 4 cm), which resolved with dextranomer/hyaluronic acid injection into the appendicovesicostomy anastomosis. This patient had resolution of incontinence with an increase in bladder capacity to 300 cc. Three patients required skin flap revision for cutaneous scarring. To date all patients are catheterizing without difficulty and are continent. Median followup was 20 months (range 3 to 29). CONCLUSIONS: We are encouraged by our preliminary experience with the robotic assisted laparoscopic Mitrofanoff appendicovesicostomy continent urinary diversion with or without ileocystoplasty. Early in the experience we emphasize the importance of 4 cm of detrusor backing to maintain stomal continence.




“Safety Profile of Robot-Assisted Radical Prostatectomy: A Standardized Report of Complications in 3317 Patients.”

Agarwal, P. K., J. Sammon, et al. (2011).

European Urology.


Background: Previous studies attempting to assess complications after robot-assisted radical prostatectomy (RARP) are limited by their small numbers, short follow-up, or lack of risk factor analysis. Objective: To document complications after RARP by strict application of standardized reporting criteria. Design, setting, and participants: Between January 2005 and December 2009, 3317 consecutive patients underwent RARP at a tertiary referral center. Median follow-up was 24.2 mo (interquartile range: 12.4-36.9). Intervention: Transperitoneal RARP was performed by one of five surgeons-two experienced, three beginners. Measurements: Complications were captured by exhaustive review of multiple datasets, including our prospective prostate cancer database, claims data, and electronic medical and institutional morbidity and mortality records, and reported according to the Martin-Donat criteria. Complications were stratified by type (medical/surgical), Clavien classification, and timing of onset. Multivariable analysis of factors predictive of complications was performed. Results and limitations: The median hospitalization time was 1 d. There were 368 complications in 326 patients (9.8%), including a transfusion rate of 2.2%. We detected 79 medical complications in 78 patients (2.4%) and 289 surgical complications in 264 patients (8.0%). There were 242 minor (Clavien 1-2) and 126 major (Clavien 3-5) complications. Two hundred ninety-nine (81.3%) complications occurred within 30 d, 17 (4.6%) within 31-90 d, and 52 (14.1%) after 90 d from surgery. On multivariable analysis, preoperative prostate-specific antigen values and cardiac comorbidity were predictive for medical complications, whereas age, gastroesophageal reflux disease, and biopsy Gleason score were predictive of surgical complications. Limitations of this study include representing results from a single high-volume referral center and not including the learning curve of the two most experienced surgeons. Conclusions: RARP is a safe operation, with an overall complication rate of 9.8%. Most complications occurred within 30 d of surgery. © 2011.




“Two Procedures at the Same Robotic Session: Robot-assisted Laparoscopic Radical Prostatectomy and Cholecystectomy.”

Akbulut, Z., A. E. Canda, et al. (2011).

Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 21(1): e34-35.


A 66-year old male patient with right upper abominal pain was diagnosed with cholelithiasis on abdominal ultrasound and elective laparoscopic cholecystectomy was recommended. His serum prostate-specific antigen was 21.3 ng/mL and underwent a 12-core transrectal ultrasound-guided prostate biopsy, which showed prostatic adenocarcinoma (Gleason score 4+4). Owing to the presence of concomitant cholelithiasis, we performed robot-assisted laparoscopic radical prostatectomy and robot-assisted laparoscopic cholecystectomy at the same session. Console time was 257 minutes. Intraoperative blood loss was 50 mL. Patient was fit to be discharged on postoperative day 2. Surgical specimen pathology showed a bilateral prostatic adenocarcinoma of Gleason score 4+3, with unilateral extracapsular extension and negative surgical margins. Currently, he is full continent with a serum prostate-specific antigen of 0.04 ng/mL on his first-month follow-up evaluation. Combined robotic approach seems to have many benefits including shorter hospital stay, decreased cost, decreased anesthesia risk, and better cosmetic results.




“Nerve-sparing technique and urinary control after robot-assisted laparoscopic prostatectomy.”

Choi, W. W., M. P. Freire, et al. (2011).

World Journal of Urology 29(1): 21-27.


Objectives: To characterize determinants of 4-, 12-, and 24-month urinary control after robot-assisted laparoscopic prostatectomy (RALP). Methods: Adjusted comparative study using prospectively collected, patient self-reported urinary control for 602 consecutive RALPs. Urinary control defined as: (1) EPIC urinary function (UF) scored from 0 to 100 and (2) continence (zero pads per day). Results: Both UF (62.8 vs. 42.4, P <0.001) and continence rates (47.2 vs. 26.7%, P = 0.043) were better for bilateral nerve-sparing (BNS) vs. non-nerve-sparing (NNS) at 4 months, but only UF scores were significantly better at 12- (80.9 vs. 70.7, P = 0.014) and 24-month (89.2 vs. 77.4, P = 0.024) post-RALP. No difference in positive margin rates was observed. In multivariate analysis, older age (parameter estimate -0.42, 95% CI -0.80 to -0.04) and increasing gland volume (-0.13, CI -0.26 to -0.01) resulted in lower UF scores at 4 months, while higher pre-operative UF (0.25, CI 0.05-0.46), bladder neck-sparing technique (10.1, CI 3.79-16.35), BNS (19.1, CI 9.37-28.82), and unilateral nerve-sparing (19.00, CI 7. 88-30.11) resulted in higher UF scores at 4 months. At 12 months, higher pre-operative UF (0.24, CI 0.083-0.40) and BNS (9.54, CI 1.92-17.16) resulted in higher UF scores. At 24 months, higher pre-operative UF (0.20, CI 0.06-0.33), bladder neck-sparing technique (7.80, CI 3.48-12.10), and BNS (7.86, CI 1.04-14.68) resulted in higher UF scores. Conclusions: BNS, bladder neck-sparing technique, and higher pre-operative UF score result in improved 24-month urinary control after RALP. © 2010 Springer-Verlag.




“Three-limb compartment syndrome and rhabdomyolysis after robotic cystoprostatectomy.”

Galyon, S. W., K. A. Richards, et al. (2011).

Journal of Clinical Anesthesia 23(1): 75-78.


The case of a 53 year-old, ASA physical status III man who underwent laparoscopy-assisted cystoprostatectomy, then subsequently developed three-limb compartment syndrome and rhabdomyolysis, is presented. He recovered baseline renal function and the use of his limbs. Well-limb compartment syndrome (WLCS) has a multifactorial etiology and is prevented and managed by avoidance of known risks. © 2011 Elsevier Inc. All rights reserved.




“Tandem-robot Assisted Laparoscopic Radical Prostatectomy to Improve the Neurovascular Bundle Visualization: A Feasibility Study.”

Han, M., C. Kim, et al. (2011).

Urology 77(2): 502-506.


OBJECTIVES: To examine the feasibility of image-guided navigation using transrectal ultrasound (TRUS) to visualize the neurovascular bundle (NVB) during robot-assisted laparoscopic radical prostatectomy (RALP). The preservation of the NVB during radical prostatectomy improves the postoperative recovery of sexual potency. The accompanying blood vessels in the NVB can serve as a macroscopic landmark to localize the microscopic cavernous nerves in the NVB. METHODS: A novel, robotic transrectal ultrasound probe manipulator (TRUS Robot) and three-dimensional (3-D) reconstruction software were developed and used concurrently with the daVinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA) in a tandem-robot assisted laparoscopic radical prostatectomy (T-RALP). RESULTS: After appropriate approval and informed consent were obtained, 3 subjects underwent T-RALP without associated complications. The TRUS Robot allowed a steady handling and remote manipulation of the TRUS probe during T-RALP. It also tracked the TRUS probe position accurately and allowed 3-D image reconstruction of the prostate and surrounding structures. Image navigation was performed by observing the tips of the daVinci surgical instruments in the live TRUS image. Blood vessels in the NVB were visualized using Doppler ultrasound. CONCLUSIONS: Intraoperative 3-D image-guided navigation in T-RALP is feasible. The use of TRUS during radical prostatectomy can potentially improve the visualization and preservation of the NVB. Further studies are needed to assess the clinical benefit of T-RALP.




“Robot-assisted prostatectomy: the new standard of care.”

Hatiboglu, G., D. Teber, et al. (2011).

Langenbeck’s Archives of Surgery: 1-10.


Introduction: Robot-assisted radical prostatectomy (RARP) has first been performed in 2000 and has since then become a widespread and often performed therapy option for surgical treatment of prostate cancer. The purpose of this review was to highlight the current clinical concepts for radical prostatectomy. Discussion and conclusions: Actual literature search was performed in PubMed database and reviewed. Different surgical techniques for RARP are presented. Oncologic and functional outcomes of RARP are discussed and compared to radical retropubic prostatectomy. In conclusion, RARP has equal oncologic and functional outcome in localized prostate cancer. RARP as a less invasive treatment option for patients with localized prostate cancer should be considered as a new standard of care by now. © 2011 Springer-Verlag.




“Immediate robot-assisted ureteral reimplantation during robotic prostatectomy in locally advanced prostate cancer.”

Jung, J. H., F. R. P. Arkoncel, et al. (2011).

Journal of Robotic Surgery: 1-3.


We report the technique and outcomes of immediate robot-assisted ureteral reimplantation due to unexpected ureteral injury during robot-assisted laparoscopic prostatectomy (RALP). A 61-year-old male was diagnosed with locally advanced prostate adenocarcinoma (T3bN0M0). Multiple positive margins at the bladder neck were noted on frozen section during RALP, and re-excision of the bladder neck was done. Unfortunately, the distal third of right ureter was transected. We immediately performed robot-assisted ureteroneocystostomy with double J stent insertion. No complications developed during the follow-up period. © 2011 Springer-Verlag London Ltd.




“Management of Rectal Injury During Robotic Radical Prostatectomy.”

Kheterpal, E., A. Bhandari, et al. (2011).



Objectives: To review the incidence and management of rectal injury in 4400 consecutive cases of robotic radical prostatectomy at a single institution. Material And Methods: From September 2001 to September 2009, 4400 patients underwent robotic radical prostatectomy. We reviewed the intraoperative and postoperative data from patients with rectal injuries. Once recognized, the rectal injuries were closed in 2 layers. Clear liquids were started the day after surgery. Healing of the vesicourethral anastomosis was confirmed by cystography 5-14 days postoperatively. Results: Rectal injuries were identified in 10 patients (0.2%). The mean patient age was 58.6 years (range 44-68), and the mean body mass index was 25.8 kg/m2 (range 22-29). The mean prostate-specific antigen level was 7.1 ng/mL (range 0.9-14.8), and the mean prostate weight was 58.9 g (range 22-102). The clinical stage was T1c, T2a, and T2c in 7, 2, and 1 patient, respectively. The preoperative Gleason score was 6, 7, and 8 in 3, 3, and 4 patients, respectively. All rectal injuries were diagnosed and repaired intraoperatively. Of the 10 patients, 9 had an uneventful postoperative course. The average urethral catheterization time for these patients was 14 days (range 6-21). One patient had gross fecal spillage and developed a rectourethral fistula requiring a delayed diverting colostomy. No perioperative mortality occurred. Conclusions: We found a low incidence of rectal injury during robotic radical prostatectomy. We have also demonstrated that rectal injuries can be managed primarily with meticulous closure with minimal morbidity. © 2011 Elsevier Inc. All rights reserved.




“Does performance of robot-assisted laparoscopic radical prostatectomy within 2weeks of prostate biopsy affect the outcome?”

Lee, S. H., M. S. Chung, et al. (2011).

International Journal of Urology 18(2): 141-146.


Objective: The aim of this study was to determine whether robot-assisted laparoscopic radical prostatectomy (RALP) performed within either 2 or 4weeks of prostate biopsy is associated with surgical difficulty or immediate postoperative outcome. Methods: Of the 121 patients that underwent RALP at our institution, 104 patients were prospectively included. Patients were sequentially divided into three groups: first patient in group A (interval from biopsy to RALP: 2weeks), second patient in group B (2-4weeks), third patient in group C (more than 4weeks), fourth patient in group A, and so on. The clinical, operative, pathological, and postoperative functional data were collected. Results: Group A consisted of 31 patients, group B of 33, and group C of 40 patients. Median patient age and median follow up were 61.1years and 14.1months, respectively. In group A, mean estimated blood loss was significantly higher than the other two groups, even though there was no significant difference in the mean console time. Postoperative complications did not make any difference among the groups. In the multivariable analysis, the interval from biopsy to surgery did not affect operative times or surgical margins, or the immediate postoperative outcomes (e.g. recovery of erectile function, continence, and biochemical recurrence). Conclusion: A short interval for less than two weeks between the prostate biopsy and the RALP seems to be feasible and safe. Further studies with larger samples are needed to corroborate these findings. © 2010 The Japanese Urological Association.




“Older age does not impact perioperative complications after robot-assisted radical prostatectomy.”

Nakamura, L. Y., R. N. Nunez, et al. (2011).

Journal of Robotic Surgery: 1-8.


To determine whether men aged 70 years and older had more perioperative complications after robot-assisted radical prostatectomy (RARP) compared with younger patients, a retrospective review was performed on patients who underwent RARP between March 2004 and September 2009. Subjects were stratified according to age into four groups (age 30-49, 50-59, 60-69, and ≥70 years). American Society of Anesthesiologists (ASA) scores were obtained. Complication rates in the perioperative period, transfusion rates, and length of stay were compared. Complications were classified using the previously validated Clavien system. There were a total of 293 patients aged 70 years and older amongst the 1,223 total subjects. ASA comorbidity scores did vary significantly amongst the different age groups, and there was modest correlation noted between ASA and age. There was no statistically significant difference amongst complication rates in men aged 70 years and older (15%) compared with the other cohorts (P = 0.832). There was also no significant difference in transfusion rates (P = 0.170) or length of stay (P = 0.131). Patients with higher ASA scores (ASA 3-4) had more Clavien I-II complications compared with patients with ASA scores of 1-2 (15.5% versus 10.3%, P = 0.03). There was no difference in transfusion rates or length of stay between the ASA scores. There are no more complications in men aged 70 years and older compared with men <70 years of age undergoing robot-assisted radical prostatectomy. RARP is a safe treatment option to offer to the selected elderly patient. © 2011 Springer-Verlag London Ltd.




“Pentafecta: A New Concept for Reporting Outcomes of Robot-Assisted Laparoscopic Radical Prostatectomy.”

Patel, V. R., A. Sivaraman, et al. (2011).

European Urology.


Background: Widespread use of prostate-specific antigen screening has resulted in younger and healthier men being diagnosed with prostate cancer. Their demands and expectations of surgical intervention are much higher and cannot be adequately addressed with the classic trifecta outcome measures. Objective: A new and more comprehensive method for reporting outcomes after radical prostatectomy, the pentafecta, is proposed. Design, setting, and participants: From January 2008 through September 2009, details of 1111 consecutive patients who underwent robot-assisted radical prostatectomy performed by a single surgeon were retrospectively analyzed. Of 626 potent men, 332 who underwent bilateral nerve sparing and who had 1 yr of follow-up were included in the study group. Measurements: In addition to the traditional trifecta outcomes, two perioperative variables were included in the pentafecta: no postoperative complications and negative surgical margins. Patients who attained the trifecta and concurrently the two additional outcomes were considered as having achieved the pentafecta. A logistic regression model was created to evaluate independent factors for achieving the pentafecta. Results and limitations: Continence, potency, biochemical recurrence-free survival, and trifecta rates at 12 mo were 96.4%, 89.8%, 96.4%, and 83.1%, respectively. With regard to the perioperative outcomes, 93.4% had no postoperative complication and 90.7% had negative surgical margins. The pentafecta rate at 12 mo was 70.8%. On multivariable analysis, patient age (p = 0.001) was confirmed as the only factor independently associated with the pentafecta. Conclusions: A more comprehensive approach for reporting prostate surgery outcomes, the pentafecta, is being proposed. We believe that pentafecta outcomes more accurately represent patients’ expectations after minimally invasive surgery for prostate cancer. This approach may be beneficial and may be used when counseling patients with clinically localized disease. © 2011 European Association of Urology.




“Robot-assisted laparoscopic prostatectomy: Surgical technique.”

Rocco, B., R. F. Coelho, et al. (2010).

Prostatectomia laparoscopica robot assistita: Tecnica chirurgica 62(3): 295-304.


Prostate tumours are among the most frequently diagnosed solid tumours in males (a total of 192,280 new cases in the USA in 2009); since the approval of the PSA test by the Food and Drug Administration in 1986, incidence has risen significantly, particularly in the ’90s; furthermore the spread of the PSA test has led to an increased frequency of cancer diagnosis at the localised stage. The standard treatment for tumour of the prostate is retropubic radical prostatectomy (RRP) which however is not morbidity-free, e.g. intraoperative bleeding, urinary incontinence and erectile dysfunction. This is why the interest of the scientific community has turned increasingly to mini-invasive surgical procedures able to achieve the same oncological results as the open procedure, but which also reduce the impact of the treatment on these patients’ quality of life. The first step in this direction was laparoscopic prostatectomy described by Schuessler in 1992 and standardised by Gaston in 1997. However, the technical difficulty inherent in this procedure has limited its more widespread use. In May 2000 Binder and Kramer published a report on the first robot-assisted prostatectomy (RARP) using the Da Vinci system (da Vinci TM, Intuitive Surgical, Sunnyvale, CA, USA). From the original experience, RARP, which exploits the advantages of an enlarged, three-dimensional view and the ability of the instruments to move with 7 degrees of freedom, the technique has spread enormously all over the world. At the time of writing, in the USA, RARP is the most common therapeutic option for the treatment of prostate tumour at localised stage. In the present study we describe the RARP technique proposed by dr. Vipul Patel, head of the Global Robotic Institute (Orlando Fl).




“Update on radical surgery for prostate cancer.”

Rubio-Briones, J., J. Casanova, et al. (2010).

Actualización en cirugía radical por carcinoma de próstata 24(4): 183-190.


Radical prostatectomy is considered the gold standard technique to treat organ confined prostate cancer. But therapeutic options like brachiitherapy, external beem radiotherapy or cryotherapy do offer similar oncological outcome with different side effects profile. All these together have actually driven surgery to minimal invasive techniques like pure laparoscopic or robot-guided radical prostatectomy. Urologists have to know all these kind of treatments, with their advantages and drawbacks, to be able to orientate patients in their final decision, knowing their comorbidities and desires, and guide the patient to the elected treatment although it was not performed in their centre. Copyright © 2010 Aran Ediciones, S. L.




“Posterior Rhabdosphincter Reconstruction During Robotic Assisted Radical Prostatectomy: Results From a Phase II Randomized Clinical Trial.”

Sutherland, D. E., B. Linder, et al. (2011).

Journal of Urology.


PURPOSE: Posterior rhabdosphincter reconstruction following radical prostatectomy was designed to improve early urinary continence. We executed a randomized clinical trial to test this conjecture in men undergoing robotic radical prostatectomy. MATERIALS AND METHODS: We conducted a phase II randomized clinical trial intended to detect a 25% difference in 3-month continence outcomes defined by a patient response of 0 or 1 to question 5 of the Expanded Prostate Cancer Index Composite questionnaire urinary domain, comparing standard running vesicourethral anastomosis (controls) to posterior rhabdosphincter reconstruction followed by standard running vesicourethral anastomosis (posterior rhabdosphincter reconstruction treated). Patients had clinically localized prostate cancer and were blinded. Surgeons were notified of computer randomization after prostate excision. Further continence outcomes were assessed by analysis of Expanded Prostate Cancer Index Composite questionnaire questions 1 and 12, International Prostate Symptom Score and 24-hour pad weights. Statistical significance was defined as p <0.05 RESULTS: A total of 94 patients were randomized, 47 to each arm. Preoperative clinical and functional variables were equivalent between study arms. There were no complications associated with either anastomotic technique. Of the 87 evaluable patients 62 (71.3%) met our 3-month continence definition. The null hypothesis was accepted, and 33 (81%) controls and 29 (63%) posterior rhabdosphincter reconstruction treated cases were continent at 3 months (chi-square p = 0.07, Fisher exact p = 0.1). Likewise there was no significant difference between arms in 24-hour pad weights (p = 0.14), International Prostate Symptom Score (p = 0.4), absence of daily leaks (p = 0.4) or perception of urinary function (p = 0.4). CONCLUSIONS: In this randomized clinical trial posterior rhabdosphincter reconstruction offered no advantage for return of early continence after robotic assisted radical prostatectomy.




“Surgical anatomy of the prostate in the ERA of radical robotic prostatectomy.”

Walz, J., M. Graefen, et al. (2011).

Current Opinion in Urology.


PURPOSE OF REVIEW: New insights in the anatomy of the prostate and the surrounding tissue evolve the technique of radical prostatectomy for the treatment of prostate cancer. RECENT FINDINGS: Regarding the course of the erectile nerves along the prostate, recent studies confirmed the presence of parasympathetic pro-erectile nerve fibers at the anterolateral aspect of the prostate. Another study of intraoperative electrostimulation of those nerves confirmed an increase in intracavernosal pressure by stimulations between the 1 and 3 o’clock position. Therefore, it is very likely that these anterior nerve fibers have an effect on erectile function. Regarding the urethral sphincter in the male, a study showed no attachment of the external sphincter to the levator ani muscle, probably resulting in an absence of a levator ani support to the continence mechanism. The male urinary sphincter seems to be in isolation responsible for urinary continence. SUMMARY: The nerve fibers at the anterolateral aspect of the prostate seem to participate in erectile function, which renders the concept of a high anterior release during nerve sparing beneficial. The isolated urinary sphincter mechanism results in the need to conserve as much urethral length as possible during radical prostatectomy to avoid urinary incontinence.




“Editorial Comment to Does performance of robot-assisted laparoscopic radical prostatectomy within 2weeks after biopsy affect the outcome?”

Yip, S. K. H. (2011).

International Journal of Urology 18(2): 146-147.