Abstrakt Urologie Leden 2012

Kane, C. (2012). “Commentary on “Surgery-related complications of robot-assisted radical cystectomy with intracorporeal urinary diversion.” Schumacher MC, Jonsson MN, Hosseini A, Nyberg T, Poulakis V, Pardalidis NP, John H, Wiklund PN, Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden Urology 2011;77:871-6.” Urol Oncol 30(1): 116.

Lau, C. S., J. Talug, et al. (2012). “Robotic-assisted laparoscopic radical cystectomy in the octogenarian.” Int J Med Robot.

BACKGROUND: The advanced age and comorbidities often associated with bladder cancer patients creates a difficult scenario regarding further management. Robotic-assisted laparoscopic radical cystectomy (RALRC) has had favorable results as a minimally invasive treatment option. We studied perioperative outcomes of RALRC in octogenarians to discern if there is any added benefit in this patient population. METHODS: One hundred and sixty robotic cystectomies have been performed between October 2003 and June 2010. We identified 24 octogenarians who underwent RALRC and form the cohort of the study. RESULTS: Mean patient age was 84.7 years and mean BMI was 24 kg/m(2) . Most of the patients in the study had serious medical comorbidities, as 82.6% of them had an ASA classification >/=3 and 95.6% had Charlson scores >/=3. There was one open conversion and two patients had positive surgical margins. There were a total of 45 complications in the study, with 14 major complications observed in the 90-day period after surgery. There were five patients who had no complications, and two patients expired as a result of multiple organ failure. At 24 months the overall, disease-free and disease-specific survivals were 51.1%, 64.3%, and 79%, respectively. The 90-day mortality rate was 8.7%. CONCLUSIONS: Octogenarians undergoing RALRC have a significant risk of morbidity and mortality. The relationship between advanced age and oncologic outcomes or complications needs to be discerned further as it relates to the octogenarian. Further study is needed to delineate the safety and efficacy of this approach. Copyright (c) 2012 John Wiley & Sons, Ltd.


Niegisch, G., P. Albers, et al. (2012). “[Robot-assisted radical cystectomy : Do we actually need a robot?].” Urologe. Ausgabe A.

Compared to radical prostatectomy robotic surgery is far from becoming the standard of care for radical cystectomy. Concerns about perioperative and oncological safety as well as patient’s benefit from this procedure may be a reason.In current publications no differences of perioperative morbidity and mortality were observed between patients undergoing open or robot-assisted radical cystectomy. Interestingly, older patients or patients with impaired health status might even profit from this technique. Though long-term data are missing, oncological results of robot-assisted radical cystectomy are encouraging. Extended lymphadenectomy is possible and positive margins are not seen more frequently. Concerning functional results (continence, potency) only little information is evaluable.In summary, operative and oncological outcomes do not seem to be impaired by robot assistance in radical cystectomy. However, whether patients or patient subgroups truly benefit from robot-assisted cystectomy needs to be elucidated in the future.


Wood, D. P. (2012). “Re: surgery-related complications of robot-assisted radical cystectomy with intracorporeal urinary diversion.” Journal of Urology 187(2): 474-475.


Gill, I. S., M. B. Patil, et al. (2012). “Zero Ischemia Anatomical Partial Nephrectomy: A Novel Approach.” Journal of Urology.

PURPOSE: We present a novel concept of zero ischemia anatomical robotic and laparoscopic partial nephrectomy. MATERIALS AND METHODS: Our technique primarily involves anatomical vascular microdissection and preemptive control of tumor specific, tertiary or higher order renal arterial branch(es) using neurosurgical aneurysm micro-bulldog clamps. In 58 consecutive patients the majority (70%) had anatomically complex tumors including central (67%), hilar (26%), completely intrarenal (23%), pT1b (18%) and solitary kidney (7%). Data were prospectively collected and analyzed from an institutional review board approved database. RESULTS: Of 58 cases undergoing zero ischemia robotic (15) or laparoscopic (43) partial nephrectomy, 57 (98%) were completed without hilar clamping. Mean tumor size was 3.2 cm, mean +/- SD R.E.N.A.L. score 7.0 +/- 1.9, C-index 2.9 +/- 2.4, operative time 4.4 hours, blood loss 206 cc and hospital stay 3.9 days. There were no intraoperative complications. Postoperative complications (22.8%) were low grade (Clavien grade 1 to 2) in 19.3% and high grade (Clavien grade 3 to 5) in 3.5%. All patients had negative cancer surgical margins (100%). Mean absolute and percent change in preoperative vs 4-month postoperative serum creatinine (0.2 mg/dl, 18%), estimated glomerular filtration rate (-11.4 ml/minute/1.73 m(2), 13%), and ipsilateral kidney function on radionuclide scanning at 6 months (-10%) correlated with mean percent kidney excised intraoperatively (18%). Although 21% of patients received a perioperative blood transfusion, no patient had acute or delayed renal hemorrhage, or lost a kidney. CONCLUSIONS: The concept of zero ischemia robotic and laparoscopic partial nephrectomy is presented. This anatomical vascular microdissection of the artery first and then tumor allows even complex tumors to be excised without hilar clamping. Global surgical renal ischemia is unnecessary for the majority of patients undergoing robotic and laparoscopic partial nephrectomy at our institution.


Guillotreau, J., G. P. Haber, et al. (2012). “Robotic Partial Nephrectomy Versus Laparoscopic Cryoablation for the Small Renal Mass.” European Urology.

BACKGROUND: Open partial nephrectomy (OPN) remains the gold standard for treatment of small renal masses (SRMs). Laparoscopic cryoablation (LCA) has provided encouraging outcomes. Robotic partial nephrectomy (RPN) represents a new promising option but is still under evaluation. OBJECTIVE: Compare the outcomes of RPN and LCA in the treatment of patients with SRMs. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analyzed the medical charts of patients with SRMs (</=4cm) who underwent minimally invasive nephron-sparing surgery (RPN or LCA) in our institution from January 1998 to December 2010. INTERVENTION: RPN and LCA. MEASUREMENTS: Perioperative complications and functional and oncologic outcomes were analyzed. RESULTS AND LIMITATIONS: A total of 446 SRMs were identified in 436 patients (RPN, n=210; LCA, n=226). Patients undergoing RPN were younger (p<0.0001), had a lower American Society of Anesthesiologists score (p<0.001), and higher baseline preoperative estimated glomerular filtration rate (eGFR) (p<0.0001). Mean tumor size was smaller in the LCA group (2.2 vs 2.4cm; p=0.004). RPN was associated with longer operative time (180 vs 165min; p=0.01), increased estimated blood loss (200 vs 75ml; p<0.0001), longer hospital stay (72 vs 48h; p<0.0001), and higher morbidity rate (20% vs 12%, p=0.015). Mean follow-ups for RPN and LCA were 4.8 mo and 44.5 mo, respectively (p<0.0001). Local recurrence rates for RPN and LCA were 0% and 11%, respectively (p<0.0001). Mean eGFR decrease after RPN and LCA was insignificant at 1 mo, at 6 mo after surgery, and during last follow-up. Limitations include retrospective study design, length of follow-up, and selection bias. CONCLUSIONS: Both techniques remain viable treatment options in the management of SRMs. A higher incidence of perioperative complications was found in patients undergoing RPN. However, the technique was not predictive of the occurrence of postoperative complications. Early oncologic outcomes are promising for RPN, which also seems to be associated with better preservation of renal function. Long-term follow-up and well-designed prospective comparative studies are awaited to corroborate these findings.


Hyams, E., P. Pierorazio, et al. (2011). “A Comparative Cost Analysis of Robotic-Assisted vs. Traditional Laparoscopic Partial Nephrectomy.” Journal of Endourology.

Introduction: Robotic-assisted laparoscopic partial nephrectomy (RPN) is supplanting traditional laparoscopy (LPN) as the technique of choice for minimally invasive nephron- sparing surgery. This evolution has resulted from potential clinical benefits, as well as proliferation of robotic systems and patient demand for robotic surgery. We sought to quantify the costs associated with use of robotics for minimally invasive partial nephrectomy (MIPN). Methods: A cost analysis was performed for 20 consecutive RPN and LPN patients at our institution from 2009-2010. Data included actual perioperative and hospitalization costs as well as professional fees. Capital costs were estimated using purchase costs and amortization of two robotic systems from 2001-2009, as well as maintenance contract costs. The estimated cost/case was obtained using total robotic surgical volume during this time period. Total estimated costs were compared between groups. A separate analysis was performed assuming “ideal” robotic utilization during a comparable time period. Results: RALPN had a cost premium of +$1066/case compared with LPN, assuming actual robotic utilization from 2001-2009. Assuming “ideal” utilization during a comparable time period, this premium decreased to +$334; capital costs per case decreased from $1907 to $1175. Tumor size, OR time, and length of stay were comparable between groups. Conclusions: RALPN is associated with a small to moderate cost premium depending on assumptions regarding robotic surgical volume. Saturated utilization of robotic systems decreases attributable capital costs, and makes comparison with laparoscopy more favorable. Purported clinical benefits of RPN (e.g. decreased warm ischemia time, increased utilization of nephron-sparing surgery) require further study, as these may have cost implications.


Kane, C. (2012). “Commentary on “Outcomes of robotic partial nephrectomy for renal masses with nephrometry score of >/=7.” White MA, Haber GP, Autorino R, Khanna R, Hernandez AV, Forest S, Yang B, Altunrende F, Stein RJ, Kaouk JH, Department of Surgery, Center for Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland, Ohio Urology 2011;77:809-13.” Urol Oncol 30(1): 115-116.


Lemos, G. C., M. Apezzato, et al. (2011). “Robotic-assisted partial nephrectomy: Initial experience in South America.” International Braz J Urol 37(4): 461-467.

Objective: To report the initial outcomes of robotic-assisted partial nephrectomy in a tertiary center in South America. Material and methods: From 11/2008 to 12/2009, a total of 16 transperitoneal robotic-assisted partial nephrectomies were performed in 15 patients to treat 18 kidney tumors. One patient with bilateral tumor had two procedures, while two patients with two synchronous unilateral tumors had a single operation to remove them. Eleven (73%) patients were male and the right kidney was affected in 7 (46%) patients. The median patient age and tumor size were 57 years old and 30 mm, respectively. Five (28%) tumors were hilar and/or centrally located. Results: The median operative time, warm ischemia time and estimated blood loss was 140 min, 27 min and 120 mL, respectively. Blood transfusion was required in one patient with bilateral tumor, and one additional pyelolithotomy was performed due to a 15mm stone located in the renal pelvis. The histopathology analysis showed 15 (83%) malignant tumors, which 10 (67%) were clear cell carcinoma. The median hospital stay was 72 hrs and no major complication was observed. Conclusion: Robotic-assisted partial nephrectomy is safe and represents a valuable option to perform minimally invasive nephron-sparing surgery.


Lucas, S. M., C. P. Sundaram, et al. “Factors That Impact the Outcome of Minimally Invasive Pyeloplasty: Results of the Multi-Institutional Laparoscopic and Robotic Pyeloplasty Collaborative Group.” Journal of Urology.

Purpose: We compared laparoscopic and robotic pyeloplasty to identify factors associated with procedural efficacy. Materials and Methods: We conducted a retrospective multicenter trial incorporating 865 cases from 15 centers. We collected perioperative data including anatomical and procedural factors. Failure was defined subjectively as pain that was unchanged or worse per medical records after surgery. Radiographic failure was defined as unchanged or worsening drainage on renal scans or worsening hydronephrosis on computerized tomography. Bivariate analyses were performed on all outcomes and multivariate analysis was used to assess factors associated with decreased freedom from secondary procedures. Results: Of the cases 759 (274 laparoscopic pyeloplasties with a mean followup of 15 months and 465 robotic pyeloplasties with a mean followup of 11 months, p <0.001) had sufficient data. Laparoscopic pyeloplasty, previous endopyelotomy and intraoperative crossing vessels were associated with decreased freedom from secondary procedures on bivariate analysis, with a 2-year freedom from secondary procedures of 87% for laparoscopic pyeloplasty vs 95% for robotic pyeloplasty, 81% vs 93% for patients with vs without previous endopyelotomy and 88% vs 95% for patients with vs without intraoperative crossing vessels, respectively. However, on multivariate analysis only previous endopyelotomy (HR 4.35) and intraoperative crossing vessels (HR 2.73) significantly impacted freedom from secondary procedures. Conclusions: Laparoscopic and robotic pyeloplasty are highly effective in treating ureteropelvic junction obstruction. There was no difference in their abilities to render the patient free from secondary procedures on multivariate analysis. Previous endopyelotomy and intraoperative crossing vessels reduced freedom from secondary procedures. © 2012 American Urological Association Education and Research, Inc.


Martin, G. L., J. N. Warner, et al. (2012). “Comparison of Total, Selective, and Nonarterial Clamping Techniques During Laparoscopic and Robot-Assisted Partial Nephrectomy.” Journal of Endourology.

Abstract Purpose: This study evaluates the feasibility, perioperative, and renal functional outcomes with total, selective, and nonarterial clamping techniques during minimally invasive partial nephrectomy. Methods: A retrospective review of laparoscopic and robot-assisted partial nephrectomies by a single surgeon from January 2007 to July 2010 was performed. Patients underwent total hilar clamping, selective (segmental) artery clamping, progressive clamping from segmental to main renal artery clamping, or resection without hilar clamping. Patient demographic, perioperative, and oncologic outcomes were analyzed. Change in renal function was assessed by glomerular filtration rate (GFR) calculation and differential function on pre- and postoperative renal scans. Results: A total of 68 patients underwent laparoscopic or robot-assisted partial nephrectomy. Those with a history of surgery for renal masses and elective conversion to radical nephrectomy were excluded. A total of 57 patients were analyzed (32 total hilar, 8 progressive arterial clamping, 13 selective arterial, and 4 without clamping). There were no significant differences in preoperative patient or disease characteristics between the groups. The progressive clamping technique was found to significantly decrease the total renal ischemia time compared with the total hilar clamp technique. There was no other significant difference in transfusion rate, complications, or other postoperative outcomes. There were no significant differences between the groups in intermediate-term (mean 411 days) renal function changes. Conclusions: Minimally invasive partial nephrectomy without vascular occlusion and with selective arterial clamping is feasible and can be safely performed. With this intermediate-term follow-up there was no clinically significant benefit seen for selective regional or nonischemic techniques.


Mason, M. D., C. A. Peters, et al. (2011). “Robotic Upper Pole Nephrectomy in Adult Patients with Duplicated Renal Collecting Systems.” Journal of Endourology.

Duplicated renal collecting systems are a common congenital anomaly, usually presenting in childhood, rarely presenting in adult life. To our knowledge only one case of robotic-assisted heminephrectomy in adults has been described. We reviewed the medical records of four adult patients with symptomatic unilateral duplicated collecting systems and nonfunctioning upper pole renal units (NFUPRU) who underwent robotic-assisted laparoscopic heminephrectomy at our institutions. Heminephrectomy for NFUPRU should be approached differently than partial nephrectomy, due to complex vascular anatomy. Patients undergoing this procedure enjoy brief hospital stays, minimal morbidity, preservation of renal function and resolution of symptoms. Robotic-assisted laparoscopy is well suited for this procedure as it allows improved visualization during dissection of the unique vascular anatomy, as well as scaling of surgeon movements and improved ergonomics.


Parikh, A. M., N. J. Toepfer, et al. (2011). “Pre-operative Aspirin Is Safe In Patients Undergoing Urologic Robotic Surgery.” Journal of Endourology.

Purpose: To determine the impact of preoperative aspirin on bleeding and other complications in patients undergoing robotic-assisted radical prostatectomy and nephrectomy. Methods: We identified all patients who underwent robotic radical prostatectomy or robotic nephrectomy by a single surgeon between August 2008 and August 2010. We compared patients in whom aspirin had not been administered for 7 days with those who received aspirin the morning of surgery. Patients on other antiplatelet agents or anticoagulants were excluded. Results: 44 patients underwent prostatectomy without recent aspirin, and 51 received preoperative aspirin. There were no significant differences between the 2 groups in terms of age, BMI, ASA score, PSA, or highest Gleason score. Operative time (182 vs. 174 min, p=0.19), median blood loss (175 vs. 100 mL, p=0.12), and duration of hospital stay (1 vs. 1 day, p=0.08) were similar between the 2 groups, respectively. No patient received a transfusion. Three patients who had not received aspirin and one who had were readmitted within 30 days. In the nephrectomy cohort, 12 patients had not received aspirin and 14 had. There were no differences in median blood loss (65 vs. 50 mL, p=0.96), median operative time (176 vs. 140 min, p=0.14), or median hospital stay (2 vs. 2 days, p=0.74). No patient received a transfusion. Conclusions: The administration of aspirin to patients undergoing robotic radical prostatectomy and nephrectomy appears to be safe. The risk of cardiovascular complications resulting from stopping aspirin may exceed the risk of perioperative bleeding and associated complications.


Seideman, C. A., Y. K. Tan, et al. (2012). “Robotic-assisted laparoendoscopic single-site pyeloplasty: technique using the da Vinci(R) Si robotic platform.” Journal of Endourology.

Conventional laparoscopic dismembered pyeloplasty (LP) is an established alternative to open pyeloplasty given equivalent intermediate-term outcomes and decreased morbidity. Laparoendoscopic single-site (LESS) pyeloplasty has the potential to further decrease the morbidity of LP, while yielding superior cosmesis. It is however technically very challenging even with the use of an accessory port, largely due to the difficulty of intracorporeal suturing through a single umbilical incision. Application of the da Vinci robotic surgical platform to LESS pyeloplasty (R-LESS) has the potential to overcome these limitations. We herein describe our technique for R-LESS pyeloplasty using the da Vinci(R) Si robot. We have found that use of the robotic system in conjunction with certain technique modifications helps to reduce the technical difficulty of LESS pyeloplasty and to shorten the physical learning curve associated with the procedure.


Tobis, S., J. K. Knopf, et al. (2012). “Robotic and Laparoscopic Partial Nephrectomy with Near Infrared Florescence Imaging.” Journal of Endourology.

Recent literature has focused on the importance of maximal nephron preservation during partial nephrectomy to avoid complications associated with chronic renal insufficiency. Accurate differentiation of tumor from normal surrounding parenchyma is critical to ensure excessive normal renal tissue is not made ischemic or excised along with the tumor. The feasibility of a novel intraoperative imaging technique to differentiate tumor from surrounding parenchyma during laparoscopic and robotic partial nephrectomy was evaluated. Patients scheduled to undergo laparoscopic or robotic partial nephrectomy were recruited from April 2009 to July 2010. The Endoscopic SPY(R) Imaging System (Novadaq, Inc. Missisaugua, Ontario, Canada) was utilized as an adjunct to intraoperative imaging in all cases. Patients received intravenous injections of indocyanine green (ICG), which was visualized intraoperatively with the near infrared (NIRF) imaging capability of the SPY scope. The degree of tumor fluorescence compared to surrounding renal parenchyma was qualitatively assessed prior to tumor resection, and partial nephrectomy was then performed with standard techniques while intermittently utilizing NIRF imaging. Nineteen patients underwent intravenous administration of ICG followed by NIRF during their partial nephrectomy. Average tumor size was 3.0 cm (range 0.8 – 5.9 cm). Thirteen masses were malignant on final pathology, and all of these were seen to be hypofluorescent compared to surrounding renal parenchyma during intraoperative imaging. The imaging behavior of benign tumors ranged from isofluorescent to hyperfluorescent compared to normal parenchyma. No complications were associated with ICG injection. Near infrared fluorescence imaging following intravenous ICG administration may be a useful intraoperative imaging tool to differentiate malignant tumors from normal renal parenchyma during laparoscopic and robotic partial nephrectomy. Advanced intraoperative imaging techniques such as this one may become increasingly helpful as more complicated tumors are resected with minimally invasive approaches.


Autorino, R. and M. De Sio (2011). “Editorial comment.” Urology 78(6): 1331.


Bilgin, T. E., S. Atici, et al. (2011). “Reply.” Urology 78(6): 1286.


Bonaros, N. (2011). “Editorial.” European Surgery – Acta Chirurgica Austriaca 43(4): 193-194.

Cost, N. G., D. G. Dajusta, et al. (2012). “Robot-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection in an Adolescent Population.” Journal of Endourology.

Abstract Laparoscopic retroperitoneal lymph node dissection (RPLND) has been shown to be safe and effective in appropriately selected pediatric and adolescent patients with paratesticular rhabdomyosarcoma (RMS) and testicular germ-cell tumors (T-GCT). While the use of robot-assisted laparoscopy has expanded rapidly in many areas, there are very limited reports of its use with RPLND. We present two cases of adolescents who were treated using robot-assisted laparoscopic RPLND (R-RPLND)-one with paratesticular RMS (PT-RMS) and one with testicular GCT (T-GCT)-with good outcomes and low morbidity.


Dangle, P. P. and R. Abaza (2012). “Robot-Assisted Repair of Ureteroileal Anastomosis Strictures: Initial Cases and Literature Review.” Journal of Endourology.

Abstract Background and Purpose: Ureteroileal anastomosis strictures are well-known complications of ileal conduit urinary diversion that occur in 4% to 8% of patients. Open surgical repair is the standard definitive treatment with minimally invasive, endoscopic approaches developed to prevent the need for major surgery when possible. Robot-assisted surgery has been applied to most primary urologic procedures, but the role of this surgery in the management of complications is undefined. We report our experience with two cases of robotic repair of ureteroileal anastomotic strictures after robot-assisted cystectomy, the first such cases to our knowledge, and review the literature regarding management of these strictures. Patients and Methods: Two patients underwent robot-assisted ureteroileal anastomosis revision for left-sided strictures of 1 and 6 cm in length after failed endoscopic management. Three ports were used in the first and four in the second procedure. The diseased segment was identified, and the healthy end of the ureter anastomosed to a new site on the conduit with a temporary stent. In the second case, the conduit was mobilized and brought to the end of the ureter for a tension-free anastomosis because of the length of the stricture. Results: Both patients were discharged on the first postoperative day without complications and are without recurrence after nearly 2 and 3 years since the robotic procedure. Conclusion: Minimally invasive definitive revision of ureteroileal anastomotic strictures is feasible with a robotic surgical approach. The advantages of robotic instrumentation allowed successful repair in two patients after previous robot-assisted cystectomy and avoided major open surgery.


Hemal, A. K., I. Stanasel, et al. (2011). “Reply by the authors.” Urology 78(6): 1444-1445.


Kasturi, S., S. S. Sehgal, et al. “Prospective Long-term Analysis of Nerve-sparing Extravesical Robotic-assisted Laparoscopic Ureteral Reimplantation.” Urology.

            Objective: To prospectively review our experience with extravesical robotic-assisted laparoscopic ureteral reimplantation to determine whether postoperative voiding dysfunction can be avoided with pelvic plexus visualization and to assess the efficacy of this approach for the treatment of vesicoureteral reflux (VUR). Methods: We prospectively followed 150 patients who underwent bilateral extravesical robotic-assisted laparoscopic ureteral reimplantation by a single surgeon at an academic institution. Each patient was followed for a 2-year period. All 150 patients had primary VUR of grade 3 or greater bilaterally, with 127 having parenchymal defects found on renal scans. All patients were toilet trained before surgical intervention. The operation was performed with an extravesical transperitoneal approach with robotic assistance using the daVinci Surgical System. All patients underwent voiding cystourethrography at 3 months postoperatively to document the resolution of VUR. Voiding dysfunction was assessed in each patient by uroflow, postvoid residual urine volume, and a validated questionnaire. Results: The operative success rate was 99.3% for VUR resolution on voiding cystourethrography. One patient with bilateral grade 5 VUR that was downgraded to unilateral grade 2 VUR was considered to have treatment failure. This patient ultimately underwent subsequent subureteral injection therapy after an episode of pyelonephritis. No patient experienced de novo voiding dysfunction. Conclusion: Bilateral nerve-sparing robotic-assisted extravesical reimplantation has the same success rate as the traditional open approaches, with minimal morbidity and no voiding complications in our series. © 2011 Elsevier Inc. All rights reserved.


Novara, G. (2012). “Editorial comment.” Journal of Urology 187(1): 195.


Orvieto, M. A. and K. C. Zorn (2011). “Reply.” Urology 78(5): 984-985.


Rowe, C. K., M. W. Pierce, et al. (2012). “A Comparative Direct Cost Analysis of Pediatric Urologic Robot-Assisted Laparoscopic Surgery vs. Open Surgery: Could Robotic Surgery be Less Expensive?” Journal of Endourology.

Purpose: Cost in health care is an increasing and justifiable concern that impacts decisions about the introduction of new devices such as the da Vinci(R) surgical robot. As equipment expenses represent only a portion of overall medical costs, we set out to make more specific cost comparisons between open and robot-assisted laparoscopic surgery. Materials and Methods: We performed a retrospective, observational, matched cohort study of 146 pediatric patients undergoing either open or robot-assisted laparoscopic urologic surgery from October 2004 to September 2009 at a single institution. Patients were matched based on surgery type, age, and fiscal year. Direct internal costs from the institution were used to compare the two surgery types across several procedures. Results: Robot-assisted surgery direct costs were 11.9% (p = 0.03) lower than open surgery. This cost difference was due primarily to the difference in hospital length of stay between patients undergoing open vs. robotic surgery (3.8 vs. 1.6 days, p < 0.001). Maintenance fees and equipment expenses were the primary contributors to robotic surgery costs, while open surgery costs were affected most by room and board expenses. When estimates of the indirect costs of robotic purchase and maintenance were included, open surgery had a lower total cost. There were no differences in follow-up times or complication rates. Conclusions: Direct costs for robot-assisted surgery were significantly lower than equivalent open surgery. Factors reducing robotic surgery costs included: a consistent and trained robotic surgery team, an extensive history of performing urologic robotic surgery, selection of patients for robotic surgery who otherwise would have had longer hospital stays after open surgery, and selection of procedures without a laparoscopic alternative. The high indirect costs of robot purchase and maintenance remain major factors, but could be overcome by high surgical volume and reduced prices as competitors enter the market.


Ahmed, F., J. Rhee, et al. (2012). “Surgical Complications After Robot-Assisted Laparoscopic Radical Prostatectomy: The Initial 1000 Cases Stratified by the Clavien Classification System.” Journal of Endourology.

Abstract Background and Purpose: Complications after robot-assisted prostatectomy are widely reported and varied. Our goal was to determine the incidence of surgical complications resulting from robot-assisted laparoscopic radical prostatectomy (RALP) during the initial phase of a new robotics program that was developed by two surgeons without laparoscopic or robotic fellowship training. A secondary goal was to see if experience changed the incidence of complications with this technology. Patients and Methods: A prospectively maintained database was used to evaluate the first 1000 consecutive patients who were treated with RALP from January 2004 to June 2009. The database was reviewed for evidence of complications in the perioperative period. All patients underwent robot-assisted laparoscopic radical prostatectomy by two surgeons. Complications were confirmed and supplemented by retrospectively reviewing the departmental morbidity and mortality reports, as well as the hospital records. The Clavien classification system, a standardized and validated scale for complication reporting, was applied to all events. The complication rate was determined per 100 patients treated and tested with logistic regression for a relationship with surgeon experience. Results: Ninety-seven (9.7%) patients experienced a total of 116 complications; 81 patients experienced a single complication and 16 patients experienced >/=2 complications. The majority of complications (71%) were either grade I or II. The complication rate decreased with experience when the first 500 cases were compared with the latter 500 cases (P=0.007). All the data were reviewed retrospectively. Involvement of residents/fellows increased as primary surgeon experience improved. Conclusions: Complications after RALP are most commonly minor, requiring expectant or medical management only, even during the initiation of a RALP program. The complication rate improved significantly during the study period.


Barry, M. J., P. M. Gallagher, et al. (2012). “Adverse Effects of Robotic-Assisted Laparoscopic Versus Open Retropubic Radical Prostatectomy Among a Nationwide Random Sample of Medicare-Age Men.” Journal of Clinical Oncology.

PURPOSERobotic-assisted laparoscopic radical prostatectomy is eclipsing open radical prostatectomy among men with clinically localized prostate cancer. The objective of this study was to compare the risks of problems with continence and sexual function following these procedures among Medicare-age men. PATIENTS AND METHODSA population-based random sample was drawn from the 20% Medicare claims files for August 1, 2008, through December 31, 2008. Participants had hospital and physician claims for radical prostatectomy and diagnostic codes for prostate cancer and reported undergoing either a robotic or open surgery. They received a mail survey that included self-ratings of problems with continence and sexual function a median of 14 months postoperatively.ResultsCompleted surveys were obtained from 685 (86%) of 797 eligible participants, and 406 and 220 patients reported having had robotic or open surgery, respectively. Overall, 189 (31.1%; 95% CI, 27.5% to 34.8%) of 607 men reported having a moderate or big problem with continence, and 522 (88.0%; 95% CI, 85.4% to 90.6%) of 593 men reported having a moderate or big problem with sexual function. In logistic regression models predicting the log odds of a moderate or big problem with postoperative continence and adjusting for age and educational level, robotic prostatectomy was associated with a nonsignificant trend toward greater problems with continence (odds ratio [OR] 1.41; 95% CI, 0.97 to 2.05). Robotic prostatectomy was not associated with greater problems with sexual function (OR, 0.87; 95% CI, 0.51 to 1.49). CONCLUSIONRisks of problems with continence and sexual function are high after both procedures. Medicare-age men should not expect fewer adverse effects following robotic prostatectomy.


Hurtes, X., M. Roupret, et al. (2012). “Anterior suspension combined with posterior reconstruction during robot-assisted laparoscopic prostatectomy improves early return of urinary continence: a prospective randomized multicentre trial.” BJU International.

Study Type – Therapy (RCT) Level of Evidence 1b What’s known on the subject? and What does the study add? Urinary incontinence is one of the major drawbacks of radical prostatectomy, regardless of the procedure used (i.e. open, laparoscopic or robotic-assisted). Several technical modifications have been described to improve postoperative continence, highlighting the role of puboprostatic ligaments and posterior reconstruction of the rhabdomyosphincter. The results obtained are inconsistent when applied to robotic surgery. The present multicentre randomized study shows that anterior suspension combined with posterior reconstruction is a safe and easy-to-perform technique for improving early continence after robotic-assisted laparoscopic prostatectomy. OBJECTIVE: * To assess the impact on urinary continence of anterior retropubic suspension with posterior reconstruction during robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: * In total, 72 patients who were due to undergo prostatectomy between July 2009 and July 2010 were prospectively randomized into two groups: group A underwent a standard RALP procedure and group B had anterior suspension and posterior reconstruction during RALP. * The primary outcome measure was urinary continence, assessed using the University of California Los Angeles Prostate Cancer Index questionnaire at 15 days, and at 1, 3 and 6 months, after surgery. Other data recorded were operation duration, blood loss, length of hospital stay, duration of bladder catheterization, complications and positive margin rate. RESULTS: * The continence rates at 15 days, and at 1, 3 and 6 months, after surgery were 3.6%, 7.1%, 15.4% and 57.9%, respectively, in group A, and 5.9%, 26.5%, 45.2% and 65.4%, respectively, in group B. The continence rates differed statistically between groups at 1 and 3 months (P = 0.047 and P = 0.016, respectively). * There was no significant difference between groups regarding complications (P = 0.8) or positive margin rate (P = 0.46). CONCLUSION: * Anterior suspension associated with posterior reconstruction during RALP improved the early return of continence, without increasing complications.


Jung, J. H., F. R. P. Arkoncel, et al. (2012). “Initial clinical experience of simultaneous robot-assisted bilateral partial nephrectomy and radical prostatectomy.” Yonsei Medical Journal 53(1): 236-239.

A 62-year-old male patient with prostate cancer and bilateral renal cell carcinoma underwent a simultaneous robot-assisted bilateral partial nephrectomy and radical prostatectomy. We describe our initial experience of combined operation with a port strategy allowing reuse of ports and surgical considerations because of prolonged pneumoperitoneum. © Yonsei University College of Medicine 2012.


Kalmar, A. F., F. Dewaele, et al. (2012). “Cerebral haemodynamic physiology during steep Trendelenburg position and CO2 pneumoperitoneum.” British Journal of Anaesthesia.

BACKGROUND: /st>The steep (40 degrees ) Trendelenburg position optimizes surgical exposure during robotic prostatectomy. The goal of the current study was to elucidate the influence of this patient positioning on cerebral blood flow and zero flow pressure (ZFP), and to assess the validity of different methods of evaluating ZFP. METHODS: /st>In 21 consecutive patients who underwent robotic endoscopic radical prostatectomy under general anaesthesia, transcranial Doppler flow velocity waveforms and invasive arterial and central venous pressure (CVP) waveforms suitable for analysis were recorded throughout the whole operative procedure in 14. The ZFP was determined by regression analysis of the pressure-flow plot and by different simplified formulas. The effective cerebral perfusion pressure (eCPP), pulsatility index (PI), and resistance index (RI) were determined. RESULTS: /st>While patients were in the Trendelenburg position, the ZFP increased in parallel with the CVP. The PI, RI, gradient between the ZFP and CVP, and the gradient between the CPP and the eCPP did not increase significantly (P<0.05) after 3 h of the steep Trendelenburg position. Using the formula described by Czosnyka and colleagues, the ZFP correlated closely with that calculated by linear regression throughout the course of the operation. CONCLUSIONS: /st>Prolonged steep Trendelenburg positioning and CO(2) pneumoperitoneum does not compromise cerebral perfusion. ZFP and eCPP are reliable variables for assessing brain perfusion during prolonged steep Trendelenburg positioning.


Kane, C. (2012). “Commentary on “Management of rectal injury during robotic radical prostatectomy.” Kheterpal E, Bhandari A, Siddiqui S, Pokala N, Peabody J, Menon M, Vattikuti Urology Institute, Henry Ford Health System, Henry Ford Hospital, Detroit, Michigan Urology 2011;77:976-9.” Urol Oncol 30(1): 113.


Kane, C. (2012). “Commentary on “Posterior reconstruction before vesicourethral anastomosis in patients undergoing robot-assisted laparoscopic prostatectomy leads to earlier return to baseline continence.” Brien JC, Barone B, Fabrizio M, Given R, Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia J Endourol 2011;25:441-5.” Urol Oncol 30(1): 114.


Kane, C. (2012). “Commentary on “Posterior rhabdosphincter reconstruction during robotic assisted radical prostatectomy: Results from a phase II randomized clinical trial.” Sutherland DE, Linder B, Guzman AM, Hong M, Frazier HA II, Engel JD, Bianco FJ Jr., Department of Urology, George Washington University, Washington, DC J Urol 2011;185:1262-7.” Urol Oncol 30(1): 114-115.


Kang, D. I., S. H. Woo, et al. (2012). “Incidence of port-site hernias following robot-assisted radical prostatectomy after the fascial closure of only the midline 12-mm port site.” Journal of Endourology.

Objectives: Port-site hernias are a rare complication occurring in approximately 1% of all laparoscopic surgeries. With the use of bladeless, blunt-tipped entry trocars, some surgeons have argued that not all port sites require fascial closure. However, several cases of port-site hernia have recently been reported with the use of bladeless trocars. This study evaluated the incidence of port-site hernias following robot-assisted radical prostatectomy (RARP) as we routinely closed the fascial of only the midline 12-mm port site. Patients and Methods: From 2006 to 2009, 498 patients with localized prostate cancer underwent RARP. Bladeless dilating trocars were used in all of our patients. Routinely, six ports were used: two 12 mm, three 8 mm, and one 5 mm. Fascial closure was performed only for the midline supraumbilical 12-mm port site. Results: In 498 cases of RARP, there were two port-site hernias (0.4%, 2/498). Both cases occurred at the midline supraumbilical 12-mm camera port site. No hernia developed at non-midline port sites, including the lateral 12-mm port site. Conclusion: Trocar site hernias following RARP are rare. When bladeless dilating trocars are used, routine closure of fascia of non-midline 12-mm or smaller port sites is not necessary. Splitting the muscle and fascia without cutting likely renders routine closure of fascia unnecessary for non-midline ports that are </=12 mm.


Kowalczyk, K. J., J. M. Levy, et al. “Temporal National Trends of Minimally Invasive and Retropubic Radical Prostatectomy Outcomes from 2003 to 2007: Results from the 100% Medicare Sample.” European Urology.

Background: Although the use of minimally invasive radical prostatectomy (MIRP) has increased, there are few comprehensive population-based studies assessing temporal trends and outcomes relative to retropubic radical prostatectomy (RRP). Objective: Assess temporal trends in the utilization and outcomes of MIRP and RRP among US Medicare beneficiaries from 2003 to 2007. Design, setting, and participants: A population-based retrospective study of 19 594 MIRP and 58 638 RRP procedures was performed from 2003 to 2007 from the 100% Medicare sample, composed of almost all US men ≥65 yr of age. Intervention: MIRP and RRP. Measurements: We measured 30-d outcomes (cardiac, respiratory, vascular, genitourinary, miscellaneous medical, miscellaneous surgical, wound complications, blood transfusions, and death), cystography utilization within 6 wk of surgery, and late complications (anastomotic stricture, ureteral complications, rectourethral fistulae, lymphocele, and corrective incontinence surgery). Results and limitations: From 2003 to 2007, MIRP increased from 4.9% to 44.5% of radical prostatectomies while RRP decreased from 89.4% to 52.9%. MIRP versus RRP subjects were younger (p < 0.001) and had fewer comorbidities (p < 0.001). Decreased MIRP genitourinary complications (6.2-4.1%; p = 0.002), miscellaneous surgical complications (4.7-3.7%; p = 0.030), transfusions (3.5-2.2%; p = 0.005), and postoperative cystography utilization (40.3-34.1%; p < 0.001) were observed over time. Conversely, overall RRP perioperative complications increased (27.4-32.0%; p < 0.001), including an increase in perioperative mortality (0.5-0.8%, p = 0.009). Late RRP complications increased, with the exception of fewer anastomotic strictures (10.2-8.8%; p = 0.002). In adjusted analyses, RRP versus MIRP was associated with increased 30-d mortality (odds ratio [OR]: 2.67; 95% confidence interval [CI], 1.55-4.59; p < 0.001) and more perioperative (OR: 1.60; 95% CI, 1.45-1.76; p < 0.001) and late complications (OR: 2.52; 95% CI, 2.20-2.89; p < 0.001). Limitations include the inability to distinguish MIRP with versus without robotic assistance and also the lack of pathologic information. Conclusions: From 2003 to 2007, there were fewer MIRP transfusions, genitourinary complications, and miscellaneous surgical complications, whereas most RRP perioperative and late complications increased. RRP versus MIRP was associated with more postoperative mortality and complications. © 2011.


Lane, T. (2012). “Editorial comment: Assessment of complication and functional outcome reporting in the minimally invasive prostatectomy literature from 2006 to the present.” BJU International 109(1): 630.


Masterson, T. A., L. Cheng, et al. (2012). “Open vs. robotic-assisted radical prostatectomy: A single surgeon and pathologist comparison of pathologic and oncologic outcomes.” Urol Oncol.

OBJECTIVE: To compare the impact surgical technique has on clinicopathologic and oncologic outcomes among patients undergoing radical prostatectomy for clinically localized prostate cancer. MATERIALS AND METHODS: Utilizing the experience of a single surgeon and pathologist, a retrospective review of 1,041 patients undergoing open (RRP) and robotic-assisted (RALP) radical prostatectomy between 1999 and 2010 with pathologic evaluation using whole-mount sectioning techniques and tumor mapping was performed from our prospective database. Differences in the incidence, location, and linear length of positive surgical margins were compared. Additionally, rates of biochemical relapse-free survival according to technique were assessed. RESULTS: A total of 357 RRP and 669 RALP patients were evaluated. The overall incidence of surgical margin positivity when stratified by stage of disease and location of positive margins was nearly identical between groups for organ confined disease. The apex and posterior surfaces represented the 2 most common locations for positive margins. RALP had notably fewer positive margins in pathologic T3 disease and a statistically shorter linear length of margin positivity among all patients. Short and intermediate-term biochemical-free survival rates were identical between groups. CONCLUSIONS: RALP is associated with operative oncologic control rates that compare very favorably to RRP. The data suggest that in the hands of an experienced surgeon, RALP has oncologic outcomes that are at least as good if not better than RRP.


Meeks, J. J. and J. A. Eastham (2012). “Robotic Prostatectomy: The Rise of the Machines or Judgment Day.” European Urology.


Mullins, J. K., M. E. Hyndman, et al. (2011). “Comparison of extraperitoneal and transperitoneal pelvic lymph node dissection during minimally invasive radical prostatectomy.” Journal of Endourology 25(12): 1883-1887.

Background and Purpose: Pelvic lymph node dissection (PLND) during radical prostatectomy (RP) has prognostic and possible therapeutic benefits. We assessed whether an extraperitoneal minimally invasive RP (MiRP) allows for standard-template PLND comparable to transperitoneal MiRP+PLND. Patients and Methods: A retrospective clinicopathologic study of 914 consecutive patients who underwent MiRP (laparoscopic or Da Vinci robot-assisted laparoscopic) with bilateral PLND by one surgeon (CPP) from 2001 to 2010 was performed. Low-risk patients generally received a limited dissection (external iliac nodes) when PLND was performed. Those with intermediate- and high-risk disease generally received a standard PLND (external iliac and obturator nodes). Patients were stratified into groups based on operative approach (extraperitoneal vs transperitoneal) for most analyses. Results: Overall, 192 patients had transperitoneal MiRP+PLND, and 377 had extraperitoneal MiRP+PLND. The extraperitoneal group had higher body mass index (P=0.03), a higher percentage of low-risk (P=0.003), and a lower percentage of intermediate-risk disease (P=0.006). Lymph node yield (LNY) was higher with extraperitoneal PLND overall (6.5 vs 5.3, P=0.003). When stratified by risk category, LNY was greater in the extraperitoneal group for patients with low-risk disease only (6.6 vs 4.9, P=0.008). There was no difference in nodal yield in intermediate/high-risk patients receiving standard PLND by either the transperitoneal or extraperitoneal approach (6.0 vs 5.5, P=0.36 and 8.0 vs 5.8, P=0.14, respectively). Lymph node involvement was rare overall. Estimated blood loss and complication rates were comparable between operative approaches. Conclusion: The extraperitoneal MiRP approach does not compromise the oncologic efficacy or safety of routine PLND. © Mary Ann Liebert, Inc.


Nunez-Nateras, R., K. J. Hurd, et al. (2011). “Athermal nerve sparing robot-assisted radical prostatectomy: initial experience with microporous polysaccharide hemospheres as a topical hemostatic agent.” World Journal of Urology.

PURPOSE: Microporous polysaccharide hemospheres (MPH) are hemostatic beads engineered from plant starch to accelerate the natural clotting cascade. The purpose of this report is to detail our initial experience with MPH as a topical hemostatic agent during robot-assisted radical prostatectomy (RARP). METHODS: We examined a single surgeon series of 30 consecutive RARP’s dividing patients into MPH or non-MPH groups. The last ten procedures utilized the MPH, which were matched 1:2 to non-MPH procedures for comparison. Nerve-sparing procedures were performed when clinically indicated and all done athermally. All demographic data, length of operation, margin status, blood loss, change in hemoglobin, and need for blood transfusion were prospectively collected and analyzed. RESULTS: The baseline characteristics were the same. The post-operative decrease in hemoglobin was less in the MPH group (1.8 g/dL MPH group vs. 3.2 g/dL non-MPH). One patient in each group required a blood transfusion. CONCLUSIONS: These preliminary findings support the role for MPH as a potential hemostatic agent during athermal nerve-sparing RARP.


Parikh, A. M., N. J. Toepfer, et al. (2011). “Pre-operative Aspirin Is Safe In Patients Undergoing Urologic Robotic Surgery.” Journal of Endourology.

Purpose: To determine the impact of preoperative aspirin on bleeding and other complications in patients undergoing robotic-assisted radical prostatectomy and nephrectomy. Methods: We identified all patients who underwent robotic radical prostatectomy or robotic nephrectomy by a single surgeon between August 2008 and August 2010. We compared patients in whom aspirin had not been administered for 7 days with those who received aspirin the morning of surgery. Patients on other antiplatelet agents or anticoagulants were excluded. Results: 44 patients underwent prostatectomy without recent aspirin, and 51 received preoperative aspirin. There were no significant differences between the 2 groups in terms of age, BMI, ASA score, PSA, or highest Gleason score. Operative time (182 vs. 174 min, p=0.19), median blood loss (175 vs. 100 mL, p=0.12), and duration of hospital stay (1 vs. 1 day, p=0.08) were similar between the 2 groups, respectively. No patient received a transfusion. Three patients who had not received aspirin and one who had were readmitted within 30 days. In the nephrectomy cohort, 12 patients had not received aspirin and 14 had. There were no differences in median blood loss (65 vs. 50 mL, p=0.96), median operative time (176 vs. 140 min, p=0.14), or median hospital stay (2 vs. 2 days, p=0.74). No patient received a transfusion. Conclusions: The administration of aspirin to patients undergoing robotic radical prostatectomy and nephrectomy appears to be safe. The risk of cardiovascular complications resulting from stopping aspirin may exceed the risk of perioperative bleeding and associated complications.


Patel, V. R., O. Schatloff, et al. (2011). “The Role of the Prostatic Vasculature as a Landmark for Nerve Sparing During Robot-Assisted Radical Prostatectomy.” European Urology.

BACKGROUND: Macroscopic landmarks are lacking to identify the cavernosal nerves (CNs) during radical prostatectomy. The prostatic and capsular arteries run along the lateral border of the prostate and could help identify the location of the CNs during robot-assisted radical prostatectomy (RARP). OBJECTIVE: Describe the visual cues that have helped us achieve consistent nerve sparing (NS) during RARP, placing special emphasis on the usefulness of the prostatic vasculature (PV). DESIGN, SETTING, AND PARTICIPANTS: Retrospective video analysis of 133 consecutive patients who underwent RARP in a single institution between January and February 2011. SURGICAL PROCEDURE: NS was performed using a retrograde, antegrade, or combined approach. MEASUREMENTS: A landmark artery (LA) was identified running on the lateral border of the prostate corresponding to either a prostatic or capsular artery. NS was classified as either medial or lateral to the LA. The area of residual nerve tissue on surgical specimens was measured to compare the amount of NS between the groups. RESULTS AND LIMITATIONS: We could identify an LA in 73.3% (195 of 266) of the operated sides. The area of residual nerve tissue was significantly different whether the NS was performed medial (between the LA and the prostate) or lateral to the LA (between the LA and pelvic side wall): median (interquartile range) of 0 (0-3) mm(2) versus14 (9-25) mm(2); p<0.001, respectively. CONCLUSIONS: The PV is an identifiable landmark during NS. Fine tailoring on the medial border of an LA can consistently result in a complete or almost complete NS, whereas performing the NS on its lateral border results in several degrees of incomplete NS.


Rocco, B., G. Albo, et al. (2011). “Recent advances in the surgical treatment of benign prostatic hyperplasia.” Therapeutic Advances in Urology 3(6): 263-272.

TURP for many years has been considered the gold standard for surgical treatment of BPH. Symptoms relief, improvement in Maximum flow rate and reduction of post void residual urine have been reported in several experiences. Notwithstanding a satisfactory efficacy, concerns have been reported in terms of safety outcomes:intracapsular perforation, TUR syndrome, bleeding with a higher risk of transfusion particularly in larger prostates have been extensivelyreported in the literature. In the recent years the use of new forms of energy and devices suchas bipolar resector, Ho: YAG and potassium-titanyl- phosphate laserare challenging the role of traditional TURP for BPH surgical treatment.In 1999 TURP represented the 81% of surgical treatment for BPHversus 39% of 2005. Is this a marketing driven change or is there areal advantage in new technologies?We analyzed guidelines and higher evidence studies to evaluate therole of the most relevant new surgical approaches compared to TURPfor the treatment of BPH.In case of prostates of very large size the challenge is ongoing, withminimally invasive laparoscopic approach and most recently roboticapproach. We will evaluate the most recent literature on thisemerging field. © SAGE Publications 2011.


Romero-González, R. J., J. F. López-Verdugo, et al. (2011). “Robot-assisted laparoscopic radical cystoprostatectomy and construction of totally intra-abdominal orthotopic bladder with ileal segment. Initial experience in Mexico.” Cirugia y Cirujanos 79(5): 434-437.

Background: Bladder and surrounding tissue resection followed by creation of a continent urinary reservoir is the gold standard treatment for invasive bladder cancer. In recent years, the da Vinci robot has played a major role in this procedure. Our objective was to describe our surgical technique, a robot-assisted laparoscopic radical cystoprostatectomy and totally intra-abdominal ortothopic ileal neobladder construction (Studer). Clinic case: We present the case of a 79-year-old male patient with a diagnosis of transitional cell bladder carcinoma. The patient underwent radical cystoprostatectomy with urinary diversion. The procedure was performed with the use of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA). Total operative time was 7 h, and the estimated blood loss was 500 ml. There were no intra- or postoperative complications, and the patient’s hospitalization was 7 days. At early follow-up, oncological and functional results were favorable. Conclusions: Robot-assisted cystoprostatectomy and urinary diversion are feasible techniques, although their role in management of infiltrative bladder cancer is not well defined.


Schatloff, O., S. Chauhan, et al. (2012). “Anatomic Grading of Nerve Sparing During Robot-Assisted Radical Prostatectomy.” European Urology.

BACKGROUND: Because of the lack of intraoperative visual cues, the amount of nerve sparing (NS) intended by the surgeon does not always correspond to what is actually performed during surgery. OBJECTIVE: Describe a standardized NS grading system based on intraoperative visual cues. DESIGN, SETTING, AND PARTICIPANTS: A total of 133 consecutive patients who underwent robot-assisted radical prostatectomy (RARP) by a single surgeon were evaluated. The surgeon intraoperatively graded the NS independently for either side as follows: 1=no NS; 2=<50% NS; 3=50% NS; 4=75% NS; 5=>/=95% NS. SURGICAL PROCEDURE: RARP; detailed description of a five-point NS grading system. MEASUREMENTS: The area of residual nerve tissue on prostatectomy specimens was compared with the intraoperative NS score (NSS). The rate of positive surgical margins (PSMs) according to the NSS is also reported. RESULTS AND LIMITATIONS: In all, 52.6% of operated sides (140 of 266 sides) had NSS 5, 30.1% (80 of 266) had NSS 4, 2.3% (6 of 266) had NSS 3, 13.2% (35 of 266) had NSS 2, and 1.9% (5 of 266) had NSS 1. The area of residual nerve tissue was significantly different among the different NSSs: median area (interquartile range) for NSS 5: 0.5 (0-2) mm(2); for NSS 4: 3 (0-8) mm(2); for NSS 3: 13 (7-23) mm(2); for NSS 2: 14 (8-24) mm(2); and for NSS 1: 57 (56-165) mm(2) (p<0.001). Overall, 9.02% of the patients (12 of 133 patients) had a PSM, with 8.3% (9 of 108) for pT2 and 12% (3 of 25) for pT3. Side-specific PSMs according to NSS were 3.6% (5 of 140) for NSS 5, 7.5% (6 of 80) for NSS 4, 16.7% (1 of 6) for NSS 3, 5.7% (2 of 35) for NSS 2, and 0% (0 of 5) for NSS 1. A limitation of our study is that the key anatomic landmarks are not recognizable in every case, and this technique might not be easy to perform during the early learning curve. CONCLUSIONS: We believe that the visual cues exposed in this article will help surgeons achieve more consistent NS during RARP.


Schroeck, F. R., T. L. Krupski, et al. (2012). “Pretreatment Expectations of Patients Undergoing Robotic Assisted Laparoscopic or Open Retropubic Radical Prostatectomy.” Journal of Urology.

PURPOSE: We previously found that patients undergoing robotic assisted laparoscopic radical prostatectomy vs radical retropubic prostatectomy had a higher likelihood of not being satisfied, independent of side effect profile. We hypothesized that differential preoperative expectations might contribute to this finding. In the current study we compared expectations of patients undergoing robotic assisted laparoscopic radical prostatectomy vs radical retropubic prostatectomy. MATERIALS AND METHODS: A questionnaire on expectations regarding recovery was administered to 171 patients electing to undergo robotic assisted laparoscopic radical prostatectomy or radical retropubic prostatectomy from 2008 to 2010. We prospectively collected data on patient expectations before surgery. Differences between patients undergoing robotic assisted laparoscopic radical prostatectomy vs radical retropubic prostatectomy were assessed with adjusted proportional odds models. RESULTS: Patients who underwent robotic assisted laparoscopic radical prostatectomy (97) did not differ significantly from those treated with radical retropubic prostatectomy (74) in age, race, income, time between survey and surgery, and prostate specific antigen (p >/=0.4). Patients who underwent radical retropubic prostatectomy had significantly higher clinical stage and Gleason grade disease (p </=0.007). After adjusting for socioeconomic factors, clinical stage and grade on multivariate analysis, patients who underwent robotic assisted laparoscopic radical prostatectomy expected a significantly shorter length of stay (OR 0.07, p <0.001) and earlier return to physical activity (OR 0.36, p = 0.005). The choice of robotic assisted laparoscopic radical prostatectomy (OR 0.41, p = 0.012), younger age (OR 0.49, p = 0.001) and higher preoperative International Index of Erectile Function-5-item version score (OR 0.60, p = 0.017) were independently associated with the expectation of earlier return of erections but not of continence on multivariate analysis. CONCLUSIONS: The body of evidence surrounding robotic assisted laparoscopic radical prostatectomy supports shorter hospitalization but there is no conclusive evidence that the robotic approach results in earlier return to physical activity or improved disease specific outcomes. Nonetheless we found that patients who underwent robotic assisted laparoscopic radical prostatectomy had higher expectations regarding these outcomes, particularly that of erectile function recovery, than did their radical retropubic prostatectomy counterparts.


Trinh, Q. D., J. Sammon, et al. “Perioperative Outcomes of Robot-Assisted Prostatectomy Compared With Open Radical Prostatectomy: Results From the Nationwide Inpatient Sample.” European Urology.

Background: Prior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates. Objective: Assess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARP’s supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique. Design, setting, and participants: As of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP (n = 11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients (n = 7389). Intervention: All patients underwent RARP or ORP. Measurements: We compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score-matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors. Results and limitations: Of 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score-matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.28-0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31-0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77-0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26-0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up. Conclusions: RARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes. © 2011 European Association of Urology.


Tsivian, M., D. E. Zilberman, et al. (2012). “Apical Surgical Margins Status in Robot-Assisted Laparoscopic Radical Prostatectomy Does Not Depend on Disease Characteristics.” Journal of Endourology.

Abstract Background and Purpose: Positive surgical margins (PSM) during robot-assisted laparoscopic radical prostatectomy (RALP) are generally considered an adverse event. We attempted to identify the factors associated with PSM and their location. Patients and Methods: Records of patients undergoing RALP between 2003 and 2009 were retrospectively reviewed. We collected demographic (age, race, body mass index [BMI]), cumulative surgical experience (years from RALP introduction at our center), clinical (prostate-specific antigen [PSA] levels, and biopsy Gleason sums), nerve-sparing technique (yes/no), and pathological variables, including stage (organ-confined vs. non), Gleason sums, prostate weight, status, and location of the surgical margins. Multivariate regression models were constructed to identify the factors associated with PSM at prostate apex, periphery, proximal, and all locations. Results: A total of 560 patients were analyzed. Median age was 60.1 (interquartile range [IQR] 55.1-64.7), 19% were African-Americans, median BMI was 28.1 (25.8-30.8 kg/m(2)), PSA levels were 5.3 (3.9-7.1 ng/mL), and prostate weight was 45.2 (36.8-57.0 g). Gleason sums were as follows: </=6 in 42.5%, 7 in 53.4%, and >7 in 3.1%. Overall, PSM were reported in 130 (23.2%), including 58 (44.6%) apical, 81 (62.3%) peripheral, and 20 (15.4%) proximal. The overall rate of PSM was associated with surgical experience, PSA, prostate weight, and Gleason sums. Apical PSM were independently associated only with surgical experience. Peripheral PSM were associated with PSA, stage, Gleason sums, and prostate weight. Finally, proximal margin status showed an association with PSA levels only. Conclusions: While peripheral, proximal, and overall PSM are largely associated with inherent disease biology (grade, PSA levels, etc.), apical margin status is independently associated only with cumulative surgical experience. These results suggest that a lower rates of positive apical margins may be obtained as the cumulative center experience grows, suggesting a potential role of a “teaching learning curve,” independently from disease characteristics.


Walsh, P. C. (2012). “Re: stepwise approach for nerve sparing without countertraction during robot-assisted radical prostatectomy: technique and outcomes.” Journal of Urology 187(2): 500.


Weber, C. (2011). “Diagnostics and therapy of localized prostate cancer: A problem-oriented account.” Diagnostik und Therapie des lokalisierten Prostatakarzinoms: Eine problemorientierte Darstellung 51(11): 930-937.

The diagnostics and treatment of prostate cancer (PCa) are currently encumbered with several problems: Only a small proportion of men attend medical check-ups. The PSA count, although invaluable in the early detection of PCa, is not being paid for by health insurance schemes, because its indiscriminate use would result in overdiagnosis of PCa which, in turn would burden patients with avoidable morbidity and the mutually supportive community with unnecessary costs. Accordingly, some clinically insignificant tumors are being detected and treated although treatment appears unnecessary. However, more importantly too many significant tumors which need early detection to be cured are being discovered too late due to diagnostic possibilities being neglected. At least one third of all tumors discovered are still found at a locally advanced stage. Following diagnosis by biopsy the therapeutic recommendations are guided by the clinical stage. In spite of recent advances in MR-based imaging the exact local extent of tumors remains uncertain. Prognostic and predictive biomarkers for aid in therapeutic decisions are also lacking. The more defensive therapeutic strategies, such as active surveillance should be recommended with special precautions in patients younger than 65 years, in the light of new Scandinavian data. Among the curative treatments radical prostatectomy claims the primary position. Minimally-invasive surgery for PCa has not come up to expectations regarding superior local tumor control, less perioperative complication, or better functional results, at the expense of appreciably higher costs. © 2011 Springer-Verlag.


Williams, S. B., A. V. D’Amico, et al. (2011). “Population-based determinants of radical prostatectomy surgical margin positivity.” BJU International 107(11): 1734-1740.

Objective To characterize factors associated with positive surgical margins (PSMs) and derive population-based PSM cutoffs to evaluate surgeon performance in radical prostatectomy (RP). Patients and Methods SEER-Medicare data were used to identify 4247 men diagnosed with prostate cancer during 2004-2005 who underwent RP up to 2006. We performed logistic regression to assess the impact of tumour characteristics, surgeon volume and surgical approach on the likelihood of PSMs for pT2 and PT3a disease. Moreover, we derived 25th and 10th percentile cutoffs from binomial distribution equations. Results Overall, 19.4% of men experienced PSMs with a pT2 vs pT3a PSM rate of 14.9% vs 42% (P < 0.001). Extrapolating from our population-based results, a surgeon incurring more than three PSMs in 10 cases of pT2 disease performed below the 25th percentile. There was a trend for fewer PSMs with minimally invasive vs open RP (17.4% vs 20.1%, P= 0.086), and the PSM rate also decreased over the study period from 21.3% in 2004 to 16.6% in 2006 (P= 0.028) with significant geographic variation (P < 0.001). In adjusted analyses, temporal and geographic variation in PSM persisted, and men with high (odds ratio 3.68, 95% CI 2.82-4.81) and intermediate (odds ratio 2.52, 95% CI 2.03-3.13) vs low-risk disease were at greater odds to experience PSMs. Notably, neither surgical approach nor surgeon volume was significantly associated with PSMs. Conclusion Our population-based PSM benchmarks allow identification of under-performing outliers who may seek courses or video self-study to improve outcomes. There was significant temporal and geographic variation in PSMs but neither surgeon volume nor surgical approach was associated with PSMs. © 2010 BJU INTERNATIONAL.


Yip, K. H., C. H. Yee, et al. (2012). “Robot-Assisted Radical Prostatectomy in Hong Kong: A Review of 235 Cases.” Journal of Endourology.

Abstract Objectives: To report the outcome of all robot-assisted laparoscopic radical prostatectomy (RALP) in the public health care system in Hong Kong. Patients and Methods: All patients who underwent RALP in the public health care system with at least 1 year of follow-up were evaluated. Data analysis included age, body mass index, preoperative prostate-specific antigen (PSA) level, D’Amico risk category, operative details, pathologic stage, follow-up continence, potency, and biochemical recurrence. Results: Between 2005 and 2009, 235 patients underwent RALP, with a mean age of 66.4+/-5.9 years and a mean preoperative PSA level of 11.0+/-10.5 ng/mL. Complications were 16 (7%) in total. There were 176 (74.9%) patients with pT(2) disease and 55 (23.4%) patients with pT(3) disease. The overall rate of positive surgical margins (PSM) was 20.7%. At postoperative 12 months, 72.5% of the patients were pad free. For those 83 preoperative potent patients having nerve-sparing surgery, the overall trifecta rate at 12 months was 37.3%. Multivariate analysis identified that pathologic T staging was significantly associated with PSM, with an odds ratio (OR) of 7.884 (95% confidence interval [CI]: 3.576-17.379; P<0.001) for the pT(3) group compared with the pT(2) group. When comparing D’Amico medium- and high-risk categories with low-risk categories, they were found to be significantly associated with biochemical failure (medium- compared with low-risk: OR=3.536, 95% CI: 1.253-10.173, P=0.016; high- compared with low-risk: OR=10.214, 95% CI: 2.958-35.274, P<0.001). Conclusions: Our data demonstrate the feasibility, safety, and efficacy of RALP in low-to-intermediate volume centers. Our early oncologic outcomes were significantly correlated with pathologic stage and D’Amico risk stratification.


Zorn, K. C., Q. D. Trinh, et al. (2012). “Prospective randomized trial of barbed polyglyconate suture to facilitate vesico-urethral anastomosis during robot-assisted radical prostatectomy: time reduction and cost benefit.” BJU International.

Study Type – RCT (randomized trial) Level of Evidence 2b What’s known on the subject? and What does the study add? In a previous randomized controlled trial, barbed polyglyconate suture for vesico-urethral anastomosis was associated with more frequent cystogram leaks, longer mean catheterization times and greater suture costs per case. In the current randomized controlled trial, we show that barbed polyglyconate suture is associated with decreased anastomosis time, decreased need to readjust suture tension, cost reduction, and equal continence and early/late urinary complication rates. OBJECTIVE: * To examine the effectiveness of barbed polyglyconate suture (V-Loc 180; Covidien, Mansfield, MA, USA) compared with standard monofilament for posterior reconstruction (PR) and vesico-urethral anastomosis (VUA) during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: * A prospective randomized controlled trial was conducted in 70 consecutive RARP cases by a single surgeon (K.C.Z.). * Standard VUA was performed using three 4-0 poliglecaprone 25 (Monocryl; Ethicon Endosurgery, Cincinnati, OH, USA) sutures secured with absorbable suture clips (LapraTy, Ethicon; one single 6-inch [15.2 cm] for PR and two attached 6-inch [15.2 cm] for VUA). * Barbed suture VUA was performed using two 3-0 6-inch (15.2 cm) barbed polyglyconate sutures. * Time to complete the suture set-up by the nursing team, anastomosis time and need to adjust suture tension were recorded. Suture-related complications, validated-questionnaire continence and cost were also examined. RESULTS: * Compared with a conventional reconstruction technique, there was a significant reduction in mean nurse set-up time (31 vs. 294 s; P < 0.01) and reconstruction time (13.1 vs. 20.8 min; P < 0.01) for the barbed suture technique. * Need to readjust suture tension or to place additional suture clips for watertight closure was greater in the standard monofilament group than in the barbed suture group (6% vs. 24%; P= 0.03). * A cost reduction was recorded at our institution (48.05 vs. 70.25 $CAN) with the barbed suture technique. * With a mean follow-up of 6.2 months, no delayed anastomotic leak or bladder neck contracture was observed in either group. * Pad-free continence outcomes for the monofilament suture vs the barbed suture groups at 1 (64 vs. 69%, P= 0.6), 3 (76 vs. 81%, P= 0.5) and 6 months (88 vs. 92%, P= 0.7) were similar. CONCLUSIONS: * Compared with standard monofilament suture, the unidirectional barbed polyglyconate suture appears to provide safe, efficient and cost-effective PR and VUA during RARP. * Use of the interlocked barbed polyglyconate suture technique prevents slippage, precluding the need for assistance, knot-tying and constant reassessment of anastomosis integrity.