Abstrakt Urologie Září 2010

“Robot-assisted radical cystectomy: An expert panel review of the current status and future direction.”

Davis, J. W., E. P. Castle, et al. (2010).

Urologic Oncology: Seminars and Original Investigations 28(5): 480-486.


Objective: At the 9th Annual Meeting of the Society of Urologic Oncology (SUO), an expert panel discussed the current status of robot-assisted radical cystectomy (RARC). Materials and methods: The presentations were derived from: (1) review of published literature, unpublished addendums, and SUO abstracts, (2) initial abstract data of pooled results of 528 patients from the International Robot-Assisted Cystectomy Consortium (IRCC), and (3) an internet-based survey of the SUO membership (n = 54) on training and practice patterns related to RARC. Results: Using pathologic assessment of surgical margins as a surrogate for cancer control, the results are favorable with organ confined disease, with select expert series showing no positive margins and the IRCC group reporting 4%. In non-organ-confined disease, select expert series also show no positive margins, while for the IRCC group it was 15%. The median lymph node yield in all series is 12-19 with 5%-33% positive. The S-model robot is preferred for an extended node dissection to the aortic bifurcation. In experienced hands, estimated blood loss is <500 cc, and hospital discharge by postoperative d 4-5. Complications appear similar to open and decrease with experience. In one study comparing RARC to open, pain scales were similar but morphine use was consistently lower for RARC. The technique is most often applied to the bladder and lymph nodes only with a mini-laparotomy for the diversion; technical considerations for female patients were described. The membership surveys showed that 37% of respondents have attempted RARC, but < 20% received robot console training during fellowship. The greatest area of concern was the adequacy of the lymph node dissection in the higher regions-common iliac to peri-caval/aortic. Conclusions: Initial reports of RARC demonstrate feasibility of technique, early oncologic outcomes, and learning curve experiences. Surgeons learning RARC should select patients without clinical evidence of locally advanced disease, and consider a second look open node dissection. Experienced surgeons have demonstrated the possibility of reduced blood loss, opiate requirement, and hospital stay. Moving forward, an international consortium has been organized to address the unmet needs of prospective comparisons with long-term oncologic outcomes, standardized complication reporting, and quality of life. © 2010 Elsevier Inc.




“Outcomes of robot-assisted radical cystectomy: Learning curves, margins and lymph node yield.”

Groves-Kirkby, N. (2010).

Nature Reviews Urology 7(9): 471.




“Commentary on “Cost analysis of robotic vs. open radical cystectomy for bladder cancer”. Angela Smith, Raj Kurpad, Anjana Lal, Matthew E. Nielsen, Eric M. Wallen, Raj S. Pruthi, Division of Urologic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC.”

Kane, C. J. (2010).

Urologic Oncology: Seminars and Original Investigations 28(5): 577.




“Bladder Diverticulum Robotic Surgery: Systematic Review of Case Reports.”

Moreno Sierra, J., I. Galante-Romo, et al. (2010).

Urologia Internationalis.


Introduction: We report one case of robot-assisted transperitoneal bladder diverticulectomy and perform a systematic review of published experience. Patient and Methods: Our patient was a 64-year-old male with a history of lower urinary tract symptoms secondary to benign prostatic enlargement for 6 years with recurrent urinary tract infection. Ultrasound and voiding cystourethrogram showed a 7-cm diverticulum in the posterior bladder wall. After bibliographic search in PubMed/Medline, 17 articles on laparoscopic diverticulectomy and 8 on robotic diverticulectomy were selected. Results: Transperitoneal robot-assisted diverticulectomy was performed with the Da Vinci 4-arm system (Intuitive Surgical Inc., Sunnyvale, Calif., USA) without perioperative complications. Operative time was 80 min and blood loss less than 100 ml. Transurethral prostatic resection combined with Greenlight laser vaporization was performed in a second step. Conclusions: Robot-assisted bladder diverticulectomy is safe, effective, reproducible and minimally invasive. Cost is higher than for laparoscopic surgery and access to this technology is limited.




“Analysis of Early Complications of Robotic-assisted Radical Cystectomy Using a Standardized Reporting System.”

Shamim Khan, M., O. Elhage, et al. (2010).



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.




“Commentary on “Prospective randomized controlled trial of robotic vs. open radical cystectomy for bladder cancer: Perioperative and pathologic results”.

Stroup, S. P. and C. J. Kane (2010). Jeff Nix, Angela Smith, Raj Kurpad, Matthew E. Nielsen, Eric M. Wallen, Raj S. Pruthi, Division of Urologic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.”

Urologic Oncology: Seminars and Original Investigations 28(5): 576.




“Initial Series of Robotic Radical Nephrectomy with Vena Caval Tumor Thrombectomy{black small square}.”

Abaza, R. (2010).

European Urology.


Laparoscopy has become a standard modality for most renal tumors but not as yet for renal cell carcinoma (RCC) involving the inferior vena cava (IVC). Robotic technology may facilitate such complex procedures. We report the first series of robotic nephrectomy with IVC tumor thrombectomy including the first cases requiring cross-clamping of the IVC in a minimally invasive fashion. Five patients underwent robotic nephrectomy with IVC tumor thrombectomy including one patient having two renal veins, each with an IVC thrombus, for a total of six IVC thrombi. The IVC was opened in all patients, and tumor thrombi were delivered intact, followed by sutured closure. The mean patient age was 64 yr (53-70 yr) with a mean body mass index of 36.6 kg/m<sup>2</sup> (22-43 kg/m<sup>2</sup>). Thrombi protruded 1 cm, 2 cm, 4 cm, and 5 cm into the IVC in five patients and 3 cm and 2 cm in the patient with two thrombi. The mean estimated blood loss was 170 ml (50-400 ml). Mean operative time was 327 min (240-411 min). Mean length of stay was 1.2 d. There were no complications, transfusions, or readmissions. This early series represents a limited experience by a single surgeon with a new procedure and may not be reproducible in larger numbers or by all surgeons. Further experience is necessary to validate this application. © 2010 European Association of Urology.




“Robotic versus laparoscopic partial nephrectomy: single-surgeon matched cohort study of 150 patients.”

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

Urology 76(3): 754-758.


OBJECTIVES: To present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or laparoscopic partial nephrectomy (LPN) by a single surgeon at a single institution. METHODS: Between March 2002 and August 2009, a retrospective review of 261 consecutive patients who underwent LPN (n = 186) or RPN (n = 75) by a single surgeon was performed. Patients were matched for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and tumor size, side, and location. Perioperative outcomes were compared. RESULTS: A matched cohort of 150 patients who underwent RPN (n = 75) or LPN (n = 75) were compared. There was no significant difference between the 2 cohorts with respect to patient age (P = .17), BMI (P = .68), ASA score (P = .96), preoperative estimated glomerulofiltration rate (eGFR; P = .54), or tumor size (P = .17). Mean operative time for RPN was 200 vs 197 minutes for LPN (P = .75). Mean estimated blood loss (EBL) was higher in the RPN cohort (323 vs 222 mL, P = .01). There was no significant difference with respect to warm ischemia time (18.2 minutes vs 20.3 minutes, P = .27), length of hospitalization (P = .84), percent change in eGFR (P = .80), or adverse events (P = .52). All surgical margins were negative. CONCLUSIONS: Although initial surgical experience with RPN was included in this study and compared with a vast experience in LPN by the same surgeon, RPN offers at least comparable outcomes to LPN.




“Robotic-assisted laparoscopic cryo-partial nephrectomy: A novel technique using cryoablation in lieu of hilar clamping in a porcine model.”

Penna, F. J., D. A. Freilich, et al. (2010).

Journal of Robotic Surgery 4(3): 191-196.


Laparoscopic and robotic-assisted partial nephrectomy has become an increasingly viable approach for the resection of renal tumors. There are several technical limitations in performing laparoscopic partial nephrectomy, the most significant being the inability to easily obtain cold ischemia which allows for an extended operative time. In this study, we evaluated the feasibility and efficacy of cryoablation as an alternative to hilar clamping to maintain hemostasis during robotic-assisted laparoscopic partial nephrectomy in a porcine model. Twelve female swine underwent nine open and eight robotic-assisted laparoscopic partial nephrectomies using modified cryoablative methods to create hemostasis. Renal perfusion imaged with indocyanine green (ICG) and histological analysis was assessed immediately after the procedure and at 3 weeks post-operatively. With two freeze/thaw cycles, all nine open and eight robotic-assisted laparoscopic partial nephrectomies were successfully completed without the need for hilar clamping. The mean blood loss for the open and robotic-assisted groups was 230.6 and 99.4 ml, respectively. In all cases, maintenance of renal perfusion was confirmed by the presence of a renal pulse and intraoperative ICG imaging immediately and 3 weeks post-operatively. The histological anatomy was well preserved in the resected segment following cryo-resection. After 21 days following cryo-resection, histological analysis demonstrated normal viable tissue with minimal scarring in the remaining kidney. The use of cryoablation created a zone of hemostasis without compromising the vascularity of the remaining kidney, while preserving the renal cytoarchitecture of the segment remove for pathological analysis. Further studies will help to delineate its usefulness in laparoscopic partial nephrectomy. © 2010 Springer-Verlag London Ltd.




“Novel application of da Vinci robotic system in patients of Zinners syndrome–case report and review of literature.”

Allaparthi, S. and R. D. Blute Jr (2010).

The Canadian journal of urology 17(2): 5109-5113.


Seminal vesicle cysts combined with ipsilateral renal agenesis, ectopic ureter and giant right ampullary cyst of vas deferens represent a rare urological anomaly, Zinners syndrome. In symptomatic patients’ seminal vesiculectomy along with enbloc excision of the ipsilateral ampullary cyst, ectopic ureter and dysplastic, renal tissue is the preferred treatment option. We report robotic assisted removal of a large seminal vesicle cyst with ipsilateral renal agenesis, ectopic ureter and a giant right ampullary cyst of vas deferens in a 34-year-old male. We reviewed the literature about this rare urological anomaly and novel usage of da Vinci surgical robotic surgical system (DSRS) (Intuitive Surgical, Sunnyvale, California) in performing this procedure.




“Laparoscopic training in urology: critical analysis of current evidence.”

Autorino, R., G. P. Haber, et al. (2010).

Journal of Endourology 24(9): 1377-1390.


AIM: To provide an evidence-based analysis on the status and perspectives of laparoscopic training in urologic surgery. METHODS: A thorough review of the current literature was performed as of January 31, 2009, using the Medline database through a PubMed search. The search protocol included a free-text query using the following terms: “training,” “urologic laparoscopy,” “urology,” and “laparoscopy.” Suitable articles were selected on the basis of the study content. The following issues were addressed: prediction of laparoscopic skills and transfer of training in clinical practice; homemade and commercially available laparoscopic trainers and simulators; training models for specific laparoscopic procedures; mentored training programs; formal training programs; and the impact of robotics in laparoscopic training. RESULTS: Currently available tools predicting laparoscopic skills lack adequate validation to justify their widespread adoption. There still is not enough evidence to show definite transfer of skills from currently available simulators to the operating theater. Learning opportunities continue to evolve. Specific models have been developed for complex procedures. Various informal training programs exist, yet most urologists will not be able to complete a formal fellowship. Postgraduate urologists may possibly be more rapidly and efficiently trained using a structured mentoring program. Robotics is likely to have an increasing role in teaching urological laparoscopy. CONCLUSIONS: Despite progress in recent years and an extensive amount of data from the urological literature, the ideal training program in urological laparoscopy remains a goal to be determined objectively.




“Application of da Vinci system for biliary operation in fifteen patients.”

Zhao, Z. M., W. B. Ji, et al. (2010).

Zhonghua yi xue za zhi 90(20): 1421-1423.


OBJECTIVE: To evaluate the efficacy of da Vinci surgical system in the treatment of biliary diseases. METHODS: The clinical data of 15 patients with biliary diseases who had undergone operations with da Vinci surgical system from March 2009 to November 2009 at our hospital were retrospectively analyzed. RESULTS: The operations were successfully performed on all patients. And no case was converted into open laparotomy. The total operative duration was 256 +/- 151 min and the robot operative duration 224 +/- 94 min. No blood transfusion was needed. Postoperative recovery time of bowl movement was 30 +/- 18 hours. And the average postoperative hospital stay was 6 +/- 3 days. Two patients had postoperative complications and were cured by conservative treatment. CONCLUSION: Various laparoscopic operations for biliary diseases may be performed with the aid of three-dimensional imaging system and flexible surgical tools of the Da Vinci surgical system. And its superiority is more obvious for complicated biliary diseases.




“Continuing Robotically? The Completion of a Robot-Assisted Radical Prostatectomy After Laparotomy.”

Brajtbord, J. S., H. J. Lavery, et al. (2010).

Journal of Endourology.


Abstract The laparoscopic management of difficult adhesions can be quite challenging for even the most experienced of laparoscopic surgeons. We describe a case of managing a suspected enterotomy with a laparotomy during a robot-assisted radical prostatectomy and the surgical options after repair. The case was complicated by a Meckel’s diverticulum fused and continuous with a urachal cyst, itself a rare occurrence. After the excision of the Meckel’s diverticulum-urachal complex, the laparotomy incision was closed, and the prostatectomy was performed robotically. We discuss the controversies regarding continuation of a planned robotic procedure after a midline laparotomy.




“Techniques of nerve-sparing and potency outcomes following robot-assisted laparoscopic prostatectomy.”

Chauhan, S., R. F. Coelho, et al. (2010).

International Braz J Urol 36(3): 259-272.


Purpose: Nerve sparing radical prostatectomy is the gold standard for the treatment of prostate cancer. Over the past decade, more and more surgeons and patients are opting for a robot-assisted procedure. The purpose of this paper is to briefly review different techniques and outcomes of nerve sparing robot assisted laparoscopic prostatectomy (RALP). Materials and Methods: We performed a MEDLINE search from 2001 to 2009 using the keywords “robotic prostatectomy”, “cavernosal nerve”, “pelvic neuroanatomy”, “potency”, “outcomes” and “comparison”. Extended search was also performed using the references from these articles. Results: Several techniques of nerve sparing are available in literature for RALP, which have been described in this manuscript. These include, “the veil of Aphrodite”, “athermal retrograde neurovascular release”, “clipless antegrade nerve sparing” and “clipless cautery free technique”. The comparative and the non comparative series showing outcomes of RALP have been described in the manuscript. Conclusions: The basic principles for nerve sparing revolve around minimal traction, athermal dissection, and approaching the correct planes. It has not been documented if any one technique is better than the other. Regardless of technique, patient selection, wise clinical judgment and a careful dissection are the keys to achieve optimal oncological outcomes following RALP.




“Early assessment of patient satisfaction and health-related quality of life following robot-assisted radical prostatectomy.”

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

Journal of Robotic Surgery: 1-7.


Impairments in health-related quality of life (HRQOL) and patient satisfaction after definitive treatment for localized prostate cancer can be significant. We assessed patient satisfaction associated with HRQOL following robot-assisted radical prostatectomy (RARP). Prostate cancer-specific HRQOL was assessed using 50 items from the Expanded Prostate Cancer Index Composite and postoperative satisfaction parameters. According to the satisfaction level, 218 consecutive patients were divided into the following three groups: group 1, extremely satisfied (n = 140); group 2, satisfied (n = 54); and group 3, uncertain, dissatisfied and extremely dissatisfied patients (n = 24). Peri-operative characteristics were not significantly different among the three groups. When the mean domain-specific HRQOL subscale scores were compared, there were no statistical differences in urinary and sexual function between groups 1 and 2. Patients in group 2 were more bothered by these domains than those in group 1. Group 3 had significantly lower scores in bowel and hormonal bother than the other groups and significantly lower scores in bowel function when compared to group 1. In daily life related to HRQOL, satisfaction is mainly determined by personal perception and interpretation rather than the objective status of urinary and sexual function. More interestingly, patients in the dissatisfied group were more likely to have bladder and bowel storage symptoms. Additional work is necessary to identify the factors associated with increased risk of pelvic organ storage symptoms following RARP. © 2010 Springer-Verlag London Ltd.




“The effect of minimally invasive and open radical prostatectomy surgeon volume.”

Choi, W. W., X. Gu, et al. (2010).

Urologic Oncology: Seminars and Original Investigations.


Objective: To determine the effect of minimally invasive radical prostatectomy (MIRP) surgeon volume on outcomes, and correlate with those of open radical prostatectomy retropubic (ORP). Methods and materials: Observational population-based study of 8,831 men undergoing MIRP and ORP by 1,457 low, medium, and high volume surgeons from SEER-Medicare linked data from 2003 to 2007. After stratifying by surgeon ORP and MIRP volume, the following outcomes were studied: length of stay, transfusions, post-operative 30-day and anastomotic stricture complications, and use of additional cancer therapies. Results: Men undergoing MIRP with high and medium vs. low volume surgeons were less likely to require additional cancer therapies (4.5% and 4.7% vs. 7%, P = 0.020). Similarly, men undergoing ORP with high vs. medium and low volume surgeons were less likely to require additional cancer therapies (5.7% vs. 6.8% and 7.1%, P = 0.044). Men undergoing ORP with high vs. medium and low volume surgeons experienced shorter lengths of stay (2.9 vs. 3.3 and 3.6 days, P < 0.001), and fewer transfusions (15.4% vs. 21.3% and 22.7%, P = 0.017), 30-day complications (18.4% vs. 25.6% and 25.7%, P < 0.001), and anastomotic strictures (10.1% vs. 15.6% and 16.3%, P = 0.003). However, MIRP surgeon volume did not affect these outcomes. Conclusions: Men undergoing MIRP or ORP with high volume surgeons were less likely to require additional cancer therapies. Additionally, patients of high volume ORP surgeons were more likely to experience shorter hospital stays, fewer transfusions, 30-day complications, and anastomotic strictures, while MIRP surgeon volume did not affect these peri-operative outcomes. © 2010 Elsevier Inc. All rights reserved.




“Influence of Modified Posterior Reconstruction of the Rhabdosphincter on Early Recovery of Continence and Anastomotic Leakage Rates after Robot-Assisted Radical Prostatectomy.”

Coelho, R. F., S. Chauhan, et al. (2010).

European Urology.


Background: Posterior reconstruction (PR) of the rhabdosphincter has been previously described during retropubic radical prostatectomy, and shorter times to return of urinary continence were reported using this technical modification. This technique has also been applied during robot-assisted radical prostatectomy (RARP); however, contradictory results have been reported. Objective: We describe here a modified technique for PR of the rhabdosphincter during RARP and report its impact on early recovery of urinary continence and on cystographic leakage rates. Design, setting, and participants: We analyzed 803 consecutive patients who underwent RARP by a single surgeon over a 12-mo period: 330 without performing PR and 473 with PR. Surgical procedure: The reconstruction was performed using two 6-in 3-0 Poliglecaprone sutures tied together. The free edge of the remaining Denonvillier’s fascia was identified after prostatectomy and approximated to the posterior aspect of the rhabdosphincter and the posterior median raphe using one arm of the continuous suture. The second layer of the reconstruction was then performed with the other arm of the suture, approximating the posterior lip of the bladder neck and vesicoprostatic muscle to the posterior urethral edge. Measurements: Continence rates were assessed with a self-administrated, validated questionnaire (Expanded Prostate Cancer Index Composite) at 1, 4, 12, and 24 wk after catheter removal. Continence was defined as the use of “no absorbent pads.” Cystogram was performed in all patients on postoperative day 4 or 5 before catheter removal. Results and limitations: There was no significant difference between the groups with respect to patient age, body mass index, prostate-specific antigen levels, prostate weight, American Urological Association symptom score, estimated blood loss, operative time, number of nerve-sparing procedures, and days with catheter. In the PR group, the continence rates at 1, 4, 12, and 24 wk postoperatively were 22.7%, 42.7%, 91.8%, and 96.3%, respectively; in the non-PR group, the continence rates were 28.7%, 51.6%, 91.1%, and 97%, respectively. The modified PR technique resulted in significantly higher continence rates at 1 and 4 wk after catheter removal (p = 0.048 and 0.016, respectively), although the continence rates at 12 and 24 wk were not significantly affected (p = 0.908 and p = 0.741, respectively). The median interval to recovery of continence was also statistically significantly shorter in the PR group (median: 4 wk; 95% confidence interval [CI]: 3.39-4.61) when compared to the non-PR group (median: 6 wk; 95% CI: 5.18-6.82; log-rank test, p = 0.037). Finally, the incidence of cystographic leaks was lower in the PR group (0.4% vs 2.1%; p = 0.036). Although the patients’ baseline characteristics were similar between the groups, the patients were not preoperatively randomized and unknown confounding factors may have influenced the results. Conclusions: Our modified PR combines the benefits of early recovery of continence reported with the original PR technique with a reinforced watertight closure of the posterior anastomotic wall. Shorter interval to recovery of continence and lower incidence of cystographic leaks were demonstrated with our PR technique when compared to RARP with no reconstruction. © 2010 European Association of Urology.




“Optimizing cancer control and functional outcomes following robotic prostatectomy.”

Correa, J. J. and J. M. Pow-Sang (2010).

Cancer Control 17(4): 233-244.


BACKGROUND: Since robotic-assisted laparoscopic radical prostatectomy was introduced, different modifications in the technique have been described to improve cancer control and minimize the possibility of erectile dysfunction and incontinence. METHODS: We reviewed the recent English literature on specific topics including when to preserve the neurovascular bundle (NVB), and we describe techniques to diminish the rate of positive margins and to preserve continence and potency. RESULTS: Identifying predictor factors of local advanced disease helps in deciding when to preserve the NVB without compromising cancer control. Techniques to decrease the positive margins based on experience and modifications of the apical dissection are reviewed. Minimal disruption or reconstruction of the anatomic structures of the periprostatic tissues helps to maintain continence. Different degrees of NVB preservation can be performed based on the characteristics of the cancer. Cautery-free techniques and other modifications in the dissection to minimize the NVB injury are also discussed. CONCLUSIONS: The understanding of the predictor factors of local advanced disease, together with modifications in the technique, helps to not only achieve cancer control but also improve quality of life after robotic-assisted laparoscopic radical prostatectomy.




“Robot-Assisted Laparoscopic Prostatectomy in Patients with Preexisting Three-Piece Inflatable Penile Prosthesis.”

Erdeljan, P., G. Brock, et al. (2010).

Journal of Sexual Medicine.


Introduction. Robotic-assisted laparoscopic radical prostatectomy (RARP) is becoming the preferred surgical treatment option for management of organ-confined prostate cancer. Although not a contraindication, previous pelvic surgery can make RARP challenging. Presence of a three-piece inflatable penile prosthesis, with a perivesical pelvic reservoir, has the potential to induce steric hindrance making RARP difficult. Aim. The main purpose of this publication is to report our experience with RARP in patients with previously inserted three-piece inflatable penile prostheses. Methods. Two patients with previously inserted AMS 700 penile prosthesis and with organ-confined, biopsy proven adenocarcinoma of the prostate underwent RARP. We describe intraoperative findings, surgical technique, oncologic and functional outcomes. Results. Both patients underwent safe and successful RARP with out any complications. Surgical margins were not affected with pelvic reservoir-sparing technique. In both patients, the penile prosthesis remained functional postoperatively. Conclusions. RARP can be safely performed in patients with previously inserted three-piece inflatable penile prosthesis. Nontraumatic handling of the pelvic reservoir is mandatory to preserve prosthesis’ integrity. Erdeljan P, Brock G, and Pautler SE. Robot-assisted laparoscopic prostatectomy in patients with preexisting three-piece inflatable penile prosthesis. J Sex Med **;**:**-**.




“Concurrent robotic trans-abdominal pre-peritoneal (TAP) herniorrhaphy during robotic-assisted radical prostatectomy.”

Joshi, A. R., J. Spivak, et al. (2010).

Int J Med Robot 6(3): 311-314.


BACKGROUND: Robotic prostatectomy (RP) is now increasingly performed because it allows for precise dissection of neurovascular structures with better outcomes. It is estimated that 5-12% of candidates for radical prostatectomy have detectable inguinal hernias, and simultaneous mesh hernioplasty is now well supported. A disadvantage of radical prostatectomy is obliteration of the preperitoneal space of Bogros, which can make future totally extraperitoneal (TEP) herniorrhaphy difficult and prone to complication. METHODS: Four patients underwent RP using the DaVinci system. Six clinically detectable inguinal hernias were repaired. Upon completion of the prostatectomy, the peritoneum overlying the myopectineal orifice of Fruchaud was opened, the orifice was dissected free and the hernia reduced. A 3 x 6 inch polypropylene mesh or 4 x 6 inch polyester mesh was then affixed overlying the orifice with titanium tacks, and the peritoneum was closed over the mesh using a running absorbable suture. RESULTS: The mean operating time for the TAP was 24 min. There were no postoperative complications. At a mean follow-up of 34 months, no recurrence was noted. CONCLUSIONS: With the increasing incidence of RP, we advocate the concurrent repair of any detectable inguinal hernias at the time of prostatectomy. The preperitoneal placement of a polypropylene or polyester mesh secured with a tacking device and a peritoneal closure performed with a running absorbable suture is uniquely suited to the abilities of the robot, and provides a durable repair.




“Outcomes after concurrent inguinal hernia repair and robotic-assisted radical prostatectomy.”

Kyle, C. C., M. K. H. Hong, et al. (2010).

Journal of Robotic Surgery: 1-4.


Inguinal hernias occur more frequently following radical prostatectomy. Simultaneous inguinal hernia repair during open and laparoscopic radical prostatectomy for prostate cancer has been described previously. The emergence of robotic-assisted radical prostatectomy (RALP) has necessitated the evaluation of concomitant herniorrhaphy in this new setting. We report the outcomes of this operation in our series of patients. Retrospective review was performed on 700 patients with localised prostate cancer who underwent RALP performed by a single surgeon from 2004 to 2009. Details of cases where concurrent inguinal hernia repair was performed were recorded and compared with the remainder of the cohort. Hernia repair was performed using a monofilament knitted polypropylene cone mesh plug and fascial defect closure with Hem-o-Lok clips. A total of 38 inguinal herniorraphies were performed in 37 patients as a simultaneous procedure during transperitoneal RALP. The hernia repair on average added 5-10 min to the total procedure time. One patient underwent a bilateral repair. Across this group, mean age was 62.9 years, average body mass index was 27.1, and median follow-up was 29 months. There were no complications at the time of mesh placement. There were no cases complicated by wound infection, fluid collection, or chronic pain. Recurrence of an inguinal hernia occurred in one patient due to migration of the mesh. We conclude that concomitant inguinal hernia repair during RALP is safe, feasible, and effective. The herniorrhaphy can be performed quickly, adds little to the overall procedure time and avoids a further operative procedure for the patient. © 2010 Springer-Verlag London Ltd.




“Discrepancies in Perception of Urinary Incontinence between Patient and Physician after Robotic Radical Prostatectomy.”

Lee, S. R., H. W. Kim, et al. (2010).

Yonsei Medical Journal 51(6): 883-887.


Purpose: Reported incidence of urinary incontinence after a radical prostatectomy (RP) varies between studies. This may be due not only to the definition of incontinence applied, but also how the information is acquired. We investigated the differences in perception of post robot-assisted laparoscopic RP (RALP) urinary incontinence acquired through doctor interviews and patient-reported questionnaires. Materials and Methods: Of 238 consecutive men who underwent RALP by a single surgeon between July 2005 and February 2008, we evaluated 66 men using the International Consultation on Incontinence Questionnaire (ICIQ) at various time points after surgery. Each patient’s ICIQ results were considered to be the patient’s perceptions of urinary incontinence. The physician at the same time directly interviewed the patients about the number of pads used and considered complete continence to be equivalent to the use of no pads or safety liners. Results: Of the 66 patients, the physician reported that 34 (51.5%) had obtained complete continence. However, analysis of the questionnaires of these 34 patients revealed that only 5 (14.7%) patients reported that they never leaked during the past 4 weeks. Most patients (11 patients, 32.4%) who did not use any pad did in fact reported leakage of a small or moderate amount of urine about once a day. Conclusion: Our results indicate that there are discrepancies in the perception of urinary incontinence between doctor and patient after RALP. Nonuse of pads is not equivalent to obtaining complete urinary continence. Therefore, the number of pads used is not a good measure to determine the status of complete urinary continence.




“Athermal Division and Selective Suture Ligation of the Dorsal Vein Complex During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of Technique and Outcomes.”

Lei, Y., M. Alemozaffar, et al. (2010).

European Urology.


Background: Apical dissection and control of the dorsal vein complex (DVC) affects blood loss, apical positive margins, and urinary control during robot-assisted laparoscopic radical prostatectomy (RALP). Objective: To describe technique and outcomes for athermal DVC division followed by selective suture ligation (DVC-SSL) compared with DVC suture ligation followed by athermal division (SL-DVC). Design, settings, and participants: Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures. Surgical procedure: RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection. Measurements: Blood loss, transfusions, operative time, apical and overall positive margins, urine leaks, catheterization duration, and urinary control at 5 and 12 mo evaluated using 1) the Expanded Prostate Cancer Index (EPIC) urinary function scale and 2) continence defined as zero pads per day. Results and limitations: Men who underwent DVC-SSL versus SL-DVC were older (mean: 59.9 vs 57.8 yr, p < 0.001), and relatively fewer white men underwent DVC-SSL versus SL-DVC (87.5% vs 96.7%, p < 0.001). Operative times were also shorter for DVC-SSL versus SL-DVC (mean: 132 vs 147 min, p < 0.001). Men undergoing DVC-SSL versus SL-DVC experienced greater blood loss (mean: 184.3 vs 175.6 ml, p = 0.033), and one DVC-SSL versus zero SL-DVC were transfused (p = 0.442). Overall (12.2% vs 12.0%, p = 1.0) and apical (1.3% vs 2.7%, p = 0.361) positive surgical margins were similar for DVC-SSL versus SL-DVC. Although 5-mo postoperative urinary function (mean: 72.9 vs 55.4, p < 0.001) and continence (61.4% vs 39.6%, p < 0.001) were better for DVC-SSL versus SL-DVC, 12-mo urinary outcomes were similar. In adjusted analyses, DVC-SSL versus SL-DVC was associated with shorter operative times (parameter estimate [PE] ± standard error [SE]: 16.84 ± 2.56, p < 0.001), and better 5-mo urinary function (PE ± SE: 19.93 ± 3.09, p < 0.001) and continence (odds ratio 3.39, 95% confidence interval 2.07-5.57, p < 0.001). Conclusions: DVC-SSL versus SL-DVC improves early urinary control and shortens operative times due to fewer instrument changes with late versus early DVC control. © 2010 European Association of Urology.




“Safety and Peri-Operative Outcomes During Learning Curve of Robot-Assisted Laparoscopic Prostatectomy: A Multi-Institutional Study of Fellowship-Trained Robotic Surgeons Versus Experienced Open Radical Prostatectomy Surgeons Incorporating Robot-Assisted Laparoscopic Prostatectomy.”

Leroy, T. J., D. D. Thiel, et al. (2010).

Journal of Endourology.


Abstract Purpose: To analyze and compare the safety and peri-operative outcomes of fellowship-trained robotic surgeons (FEL) and experienced open surgeons (OE) incorporating robot-assisted laparoscopic prostatectomy (RALP) into practice. Materials and Methods: Multiinstitutional, prospective data were collected on the first 30 RALP performed by FEL and OE (defined as over 1000 prostatectomies) incorporating RALP into practice. Morbidity from the peri-operative course was evaluated as were operative outcomes. The second 30 cases from the OE group were evaluated to assess for improvement with experience. Results: There were no rectal injuries or death in either group. Blood transfusion rates did not differ between the two groups (2% vs. 3%, p = 0.65). Open conversion occurred three times in the OE group but only within the first 30 cases. In the first 30 cases FEL had statistically lower rates of positive margins (15% vs. 34%, p = 0.008) and decreased likelihood of prolonged urethral catheter leakage (5% vs. 19%, p = 0.009). The FEL group had lower rates of failure of prostate-specific antigen to nadir <0.15 ng/mL (2% vs. 10%, p = 0.056). There were no reoperations in the FEL group but present in 2% of the OE group initially. The second 30 cases of the OE group noted a statistical improvement for all parameters with margin rates and the requirement of prolonged catheterization becoming statistically comparable to those of the FEL group. Conclusions: OE can safely incorporate RALP into practice and achieve outcomes comparable to FEL quickly. As anticipated, FEL achieve these endpoints earlier in their practice.




“Continence, potency and oncological outcomes after robotic-assisted radical prostatectomy: Early trifecta results of a high-volume surgeon.”

Patel, V. R., R. F. Coelho, et al. (2010).

BJU International 106(5): 696-702.


OBJECTIVE • To evaluate early trifecta outcomes after robotic-assisted radical prostatectomy (RARP) performed by a high-volume surgeon. PATIENTS AND METHODS • We evaluated prospectively 1100 consecutive patients who underwent RARP performed by one surgeon. In all, 541 men were considered potent before RARP; of these 404 underwent bilateral full nerve sparing and were included in this analysis. • Baseline and postoperative urinary and sexual functions were assessed using self-administered validated questionnaires. • Postoperative continence was defined as the use of no pads; potency was defined as the ability to achieve and maintain satisfactory erections for sexual intercourse >50% of times, with or without the use of oral phosphodiesterase type 5 inhibitors; Biochemical recurrence (BCR) was defined as two consecutive PSA levels of >0.2 ngmL after RARP. • Results were compared between three age groups: Group 1, ≤55 years, Group 2, 56-65 years and Group 3, >65 years. RESULTS • The trifecta rates at 6 weeks, 3, 6, 12, and 18 months after RARP were 42.8%, 65.3%, 80.3%, 86% and 91%, respectively. • There were no statistically significant differences in the continence and BCR-free rates between the three age groups at all postoperative intervals analysed. • Nevertheless, younger men had higher potency rates and shorter time to recovery of sexual function when compared with older men at 6 weeks, 3, 6 and 12 months after RARP (P < 0.01 at all time points). • Similarly, younger men also had a shorter time to achieving the trifecta and had higher trifecta rates at 6 weeks, 3 and 6 months after RARP compared with older men (P < 0.01 at all time points). CONCLUSION • RARP offers excellent short-term trifecta outcomes when performed by an experienced surgeon. • Younger men had a shorter time to achieving the trifecta and higher overall trifecta rates when compared with older men at 6 weeks, 3 and 6 months after RARP. © 2010 BJU INTERNATIONAL.




“Are the rules of “evidence based medicine” strictly followed in the field of robot-assisted laparoscopic radical prostatectomy?”

Rouprêt, M. (2010).

Les règles de la médecine fondée sur les preuves sont-elles strictement respectées dans le domaine de la prostatectomie totale laparoscopique robot-assistée ? 20(8): 596-597.




“Robot-assisted radical prostatectomy: Learning rate analysis as an objective measure of the acquisition of surgical skill.”

Sammon, J., A. Perry, et al. (2010).

BJU International 106(6): 855-860.


Study Type – Therapy (case series) Level of Evidence4 Objective To adapt an industrial definition of learning-curve analysis to surgical learning, and elucidate the rate at which experienced open surgeons acquire skills specific to robot-assisted radical prostatectomy (RARP) at a community-based medical centre. PATIENTS, SUBJECTS AND METHODS The total procedure time (TPT) of the first 75 RARPs, performed by three surgeons experienced with retropubic RP, was analysed to determine the point at which their learning rate stabilised. Operative characteristics were compared before and after this point to isolate the plateau of learning rate as a mark of acquiring surgical skill. The operative characteristics examined were TPT, estimated blood loss (EBL), bladder neck contractures (BNC), positive margins (PM) and length of hospital stay (LOS). Results The mean rate of TPT decrease, for procedures 1-75, was 13.4% per doubling of RARPs performed. After the first 25 procedures the TPT decreased at a rate of 1.8% per doubling, not significantly different from 0 (P > 0.05). There was no significant difference between procedures 1-25 and 26-75 in rates of EBL, BNC and PM. There was a significant change for all surgeons in TPT, with a mean of 303.1 min (RARPs 1-25) vs 213.6 min (26-75) (P < 0.001), and LOS, of 2.1 days (1-25) vs 1.4 days (26-75) (P < 0.001). Conclusions An industrial definition of learning-curve analysis can be adapted to provide an objective measure of learning RARP. The average learning rate for RARP was found to plateau by the 25th procedure. Also, the learning rate plateau can serve as an objective measure of the acquisition of surgical skill. © 2010 BJU INTERNATIONAL.





Seixas-Mikelus, S. A., T. Kesavadas, et al. (2010).

Urology 76(2): 361-362.




“Use of a Novel Absorbable Barbed Plastic Surgical Suture Enables a “Self-Cinching”

Tewari, A. K., A. Srivastava, et al. (2010). Technique of Vesicourethral Anastomosis During Robot-Assisted Prostatectomy and Improves Anastomotic Times.”

Journal of Endourology.


Abstract Purpose: To demonstrate a novel technique of self-cinching anastomosis using a barbed and looped suture during robot-assisted radical prostatectomy (RARP). Patients and Methods: This is a feasibility study of 50 consecutive patients who underwent this novel self-cinching anastomotic technique using a V-Loc 180 absorbable barbed suture after RARP for clinically localized prostate cancer. The results were then compared with 50 consecutive patients who underwent RARP by the same surgeon before this new technique. We examined whether this novel technique had any effects on posterior reconstruction time, vesicourethral anastomosis time, and thus total reconstruction and operative time by inference. Results: The V-Loc 180 group had significantly shorter posterior reconstruction (40 seconds vs 60 seconds; P = < 0.001) and vesicourethral anastomotic times (7 min vs 12 min; P = < 0.001). By inference, this meant that total reconstruction and operative times were also significantly less (8 minutes vs 13.5 min; P = < 0.001 and 106 min vs 114.5 minutes; P = < 0.001, respectively). Conclusion: We have shown that this technique is feasible and improves posterior reconstruction and anastomotic times. Further follow-up will determine any benefits of this technique on anastomotic urinary leak rates, continence, and catheter removal times.




“Suture versus staple ligation of the dorsal venous complex during robot-assisted laparoscopic radical prostatectomy.”

Wu, S. D., J. J. Meeks, et al. (2010).

BJU International 106(3): 385-390.


OBJECTIVES To present our operative and postoperative functional outcomes of sutured compared with endovascular staple ligation of the dorsal venous complex (DVC) during robot-assisted laparoscopic radical prostatectomy (RALP). Ligation of the DVC during RALP with an endovascular stapler has purported advantages of decreased apical positive surgical margin (PSM) rate, blood loss, and operative time when compared with suture ligation. PATIENTS AND METHODS In all, 162 patients who underwent RALP between October 2005 and April 2008 by one surgeon (R.B.N.) were assessed. We retrospectively analysed two different treatment groups: group 1 underwent DVC ligation with a single suture, while group 2 underwent endovascular staple ligation. RESULTS Of the 162 patients evaluated, 67 had suture ligation (group 1) and 95 had staple ligation (group 2) of the DVC. Baseline patient characteristics (age, body mass index, biopsy Gleason score, clinical stage) and tumour characteristics (specimen weight, tumour volume, pathological Gleason score and stage) did not differ between the groups. Estimated blood loss (494 mL vs 288 mL), time to dissect out, ligate and transect the DVC (30 min vs 24 min), apical PSM rate (13.4% vs 2.1%) differed significantly between groups 1 and 2 respectively, favouring staple ligation of the DVC. At 6 months follow-up, there was no difference between the groups for PSA recurrence (3.7% vs 0%), complete continence (63.4% vs 55.7%) and Sexual Health Inventory for Men score (8.4 vs 8.6). CONCLUSIONS In the present study, staple ligation of the DVC during RALP resulted in improved apical PSM rates, faster operative times and less blood loss. © 2010 BJU International.




“Rectal Hem-o-Lok clip migration after robot-assisted laparoscopic radical prostatectomy.”

Wu, S. D., R. R. Rios, et al. (2009).

The Canadian journal of urology 16(6): 4939-4940.


INTRODUCTION: Weck Hem-o-Lok clip migration into the bladder has been reported after robot-assisted laparoscopic radical prostatectomy (RALP). We report a case of Weck clip migration into the rectum presenting as a mass on colonoscopy. METHODS: A 61-year-old male with a prostate specific antigen level of 4.84 ng/ml underwent transrectal ultrasound guided biopsy of the prostate revealing a Gleason’s 3 + 3 adenocarcinoma of the prostate involving 20% of the sampled tissue for the left apex. He was subsequently treated with a transperitoneal robot-assisted laparoscopic radical prostatectomy and bilateral pelvic lymphadenectomy. Weck Hem-o-Lok clips were used to ligate the prostate vascular pedicles. The vesicourethral anastomosis was performed using a double armed running technique. RESULTS: Final pathology demonstrated a Gleason 4 + 3 pT2cN0Mx adenocarcinoma of the prostate with negative margins. Four lymph nodes were negative for malignancy. No intraoperative complications occurred. Postoperatively, patient was found to have a Weck Hem-o-Lok clip that migrated into his rectum. This was found on colonoscopy performed for diverticular disease of the colon. The clip was removed without complication. CONCLUSIONS: Judicious use of Weck clips during RALP and communication with physicians participating in patient care for those who have undergone RALP is crucial in minimizing complications and avoiding subsequent procedures.




“Robot-assisted extraperitoneal laparoscopic radical prostatectomy: A review of the current literature.” Xylinas, E., G. Ploussard, et al. (2010).

Urol Oncol.


Prostate cancer remains a significant health problem worldwide and is the second highest cause of cancer-related death in men. While there is uncertainty over which men will benefit from radical treatment, considerable efforts are being made to reduce treatment related side-effects and in optimizing outcomes. The current gold standard treatment for localized prostate cancer remains open radical prostatectomy. Since the early 1990s, several teams have tried to explore less invasive surgical access. The first robotically assisted laparoscopic prostatectomy (RALP) case was reported in 2000. Enhancement of the ergonomics and optimization of the surgical vision provided by the robotic interface are some of the reasons that explain the worldwide wide spread of RALP. Although this procedure accounted for the vast majority of radical prostatectomies performed in United States, its diffusion is still limited in Europe. The cost for robot purchase and maintenance are obvious limiting factors for its expansion. According to the literature, the operating time and the blood loss are, once the learning curve is completed, similar to those of open or laparoscopic procedures. Hospital stay and time before bladder catheter removal are shorter compared with other approaches. Intermediate oncologic and functional outcomes do not show difference with the open or laparoscopic results. Given that these data are encouraging, the limited follow-up with RALP does not allow drawing any definitive statement in comparison with conventional techniques. The aim of our study was to underline the perioperative, oncologic, and functional outcomes of all extraperitoneal RALP series published.