[Show abstract][Hide abstract] ABSTRACT: The objectives of this review are to summarize the current training modalities and assessment tools used in urological robotic surgery and to propose principles to guide the formation of a comprehensive robotics curriculum.
Indian journal of urology : IJU : journal of the Urological Society of India. 07/2014; 30(3):333-8.
[Show abstract][Hide abstract] ABSTRACT: Radical cystectomy is the gold-standard treatment for muscle-invasive and refractory nonmuscle-invasive bladder cancer. We describe our technique for robotic radical cystectomy (RRC) and intracorporeal urinary diversion (ICUD), that replicates open surgical principles, and present our preliminary results.
Indian journal of urology : IJU : journal of the Urological Society of India. 07/2014; 30(3):300-6.
[Show abstract][Hide abstract] ABSTRACT: There have been a number of advances in robotic partial nephrectomy (RPN) for renal masses. We reviewed these advances with emphasis on the evolution of technique and outcomes as well as the expanding indications for RPN. Literature in the English language was reviewed using the National Library of Medicine database. Relevant articles were extracted, and their citations were utilized to broaden our search. The identified articles were reviewed and summarized with a focus on novel developments. RPN is an evolving procedure and is an emerging viable alternative to laparoscopic partial nephrectomy and open partial nephrectomy with favorable outcomes. The contemporary techniques used for RPN demonstrate excellent perioperative outcomes. The short-term oncologic outcomes are comparable to those of laparoscopic and open surgical approaches. Further studies are needed to assess long-term oncologic control.
Indian journal of urology : IJU : journal of the Urological Society of India. 07/2014; 30(3):275-82.
[Show abstract][Hide abstract] ABSTRACT: Objectives: To present time-efficiency data during our initial experience with intracorporeal urinary diversion and technical tips that may shorten operative time early in the learning curve. Patients and methods: Data were analyzed in the initial 37 consecutive patients undergoing robotic radical cystectomy and intracorporeal urinary diversion in whom detailed step-wise operative time data were available. Median age was 65 years and median BMI was 27. Neoadjuvant chemotherapy was administered in 6 patients and 11 patients had clinical evidence of T3 or lymph node-positive disease. Each component of the operation was subdivided into specific steps and operative time for each step was prospectively recorded. Peri-operative and follow-up data upto 90 days and final pathological data were recorded. Results: All procedures were completed intracorporeally and robotically without need for conversion to open surgery or extracorporeal diversion. Median total operative time was 387 vs 386 minutes (p=0.2) and median total console time was 361 vs 295 minutes (p<0.007) for orthotopic neobladder and ileal conduit, respectively. Median time for radical cystectomy was 77 min, extended PLND was 63 min and diversion was 111 min (Ileal conduit 92 min, orthotopic neobladder 124 min). Median estimated blood loss was 250 cc, and median hospital stay was 9 days. High grade (Clavien grade 3-5) complications at 30 and 90 days follow up were recorded in 6 (16%) and 9 (24%) patients, respectively. Over a median follow up of 16 months, 12 (32%) patients experienced disease recurrence and 9 (24%) died from bladder cancer. These correspond to 1-year recurrence-free and overall survival of 64% and 70%, respectively. Conclusions: Intracorporeal urinary diversion following robotic radical cystectomy can be performed safely and reproducibly in a time efficient manner even during the early learning curve.
Journal of endourology / Endourological Society 06/2014; · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: To determine the feasibility and develop a robotic technique for intracorporeal implantation of a biodegradable tubular scaffold seeded with adipose-sourced smooth muscle cells (Neo-Urinary-Conduit® (NUC), Tengion®) which, when implanted as a conduit for urinary diversion, facilitates regeneration of native-like neo-urinary tissue. Material and Methods: Robotic NUC implantation was performed in two fresh male cadavers. The greater omentum was widely detached from the greater curvature of the stomach, in preparation for final wrapping of the conduit. Bilateral ureters were mobilized for implantation. The NUC, with two pre-created ureteral openings, was inserted into the abdomen. Bilateral, stented uretero-NUC anastomoses were created. The NUC was circumferentially wrapped with the pre-dissected omentum, exteriorized through the abdominal wall, and maturated. Results: Both procedures were successfully completed intracorporeally. Operative time for NUC implantation was 90 and 100 min, respectively. Examination of gross anatomy showed no injury to other organs. There was no omental kinking, rotation, eversion, or stripping from the NUC. Bilateral stents were confirmed to be in situ with the proximal coil in the kidney. Uretero-NUC anastomoses and omentum were tension-free. The entire NUC, including its distal edge and posterior aspect, was circumferentially wrapped 360 degrees. Conclusion: We demonstrated the feasibility and developed a robotic technique for intracorporeal implantation of a biodegradable regenerative urinary conduit. This study serves as the foundation for the robotic surgical technique prior to the clinical application.
Journal of endourology / Endourological Society 05/2014; · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose: To describe our technique for robotic bladder diverticulectomy (RBD). Patients and Methods: Ten patients underwent RBD using an extra- or transvesical approach. Three (30%) patients underwent concomitant procedures: robot-assisted radical prostatectomy, robotic simple prostatectomy, and transurethral resection of the prostate. Results: All RBDs were performed successfully. Median estimated blood loss, operative time and diverticulectomy time were 75ml, 210 min and 80 min, respectively. Median follow up time was 18 months. Median International Prostate Symptom Score decreased by 57%, p = 0.001. Conclusions: RBD is feasible and safe. It can be performed via a trans- or extra-vesical approach, as a standalone, or concomitant procedure.
Journal of endourology / Endourological Society 04/2014; · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The contact surface area (CSA) of a tumor with adjacent renal parenchyma may determine the complexity and thus the perioperative outcomes of partial nephrectomy (PN).
We devised a novel imaging parameter, renal tumor CSA, and correlate it with perioperative outcomes in patients undergoing PN.
Of 200 patients undergoing PN for a tumor (January 2010 to August 2011), 162 had renal protocol computed tomography scanning data available. CSA was calculated using image-rendering software (Synapse 3D, Fujifilm), and interobserver variability was determined between three independent observers.
CSA was correlated to baseline demographics and perioperative outcomes as a continuous and categorical variable using multivariable logistic regression analysis. The ability of CSA to predict adverse perioperative events was compared with demographic factors and nephrometry scoring systems.
The mean tumor size was 3.1cm; CSA was 18.3 cm(2). CSA ≥20 cm(2) correlated with adverse tumor characteristics (greater tumor size, volume, and complexity) and perioperative outcomes (more parenchymal volume loss, blood loss, and complications) compared with CSA <20 cm(2). On multivariable logistic regression, CSA independently predicted operative time, complications, hospital stay, and renal functional outcomes. This predictive ability of CSA was superior to the other parameters evaluated.
CSA is a novel imaging parameter that quantifies the CSA of renal tumor with adjacent parenchyma. Our preliminary data indicate that CSA correlates with PN outcomes. If validated externally in a larger cohort, CSA could be incorporated into future versions of nephrometry scoring systems.
In this study we outline the method of calculating the contact surface area (CSA) of renal tumors with the surrounding normal kidney using image-rendering software. We found that CSA correlates with a number of important surgical outcomes including operative time, loss of renal function, and complications.
[Show abstract][Hide abstract] ABSTRACT: Concerns have been raised regarding partial nephrectomy (PN) techniques that do not occlude the main renal artery.
Compare the perioperative outcomes of superselective versus main renal artery control during robotic PN.
A retrospective analysis of 121 consecutive patients undergoing robotic PN using superselective control (group 1, n=58) or main artery clamping (group 2, n=63).
Group 1 underwent tumor-specific devascularization, maintaining ongoing arterial perfusion to the renal remnant at all times. Group 2 underwent main renal artery clamping, creating global renal ischemia.
Perioperative and functional data were evaluated. The Pearson chi-square or Fisher exact and Wilcoxon rank sum tests were used.
All robotic procedures were successful, all surgical margins were negative, and no kidneys were lost. Compared with group 2 tumors, group 1 tumors were larger (3.4 vs 2.6cm, p=0.004), more commonly hilar (24% vs 6%, p=0.009), and more complex (PADUA 10 vs 8, p=0.009). Group 1 patients had longer median operative time (p<0.001) and transfusion rates (24% vs 6%, p<0.01) but similar estimated blood loss (200 vs 150ml), perioperative complications (15% vs 13%), and hospital stay. Group 1 patients had less decrease in estimated glomerular filtration rate at discharge (0% vs 11%, p=0.01) and at last follow-up (11% vs 17%, p=0.03). On computed tomography volumetrics, group 1 patients trended toward greater parenchymal preservation (95% vs 90%, p=0.07) despite larger tumor size and volume (19 vs 8ml, p=0.002). Main limitations are the retrospective study design, small cohort, and short follow-up.
Robotic PN with superselective vascular control enables tumor excision without any global renal ischemia. Blood loss, complications, and positive margin rates were low and similar to main artery clamping. In this initial developmental phase, limitations included more perioperative transfusions and longer operative time. The advantage of superselective clamping for better renal function preservation requires validation by prospective randomized studies.
Preserving global blood flow to the kidney during robotic partial nephrectomy (PN) does not lead to a higher complication rate and may lead to better postoperative renal function compared with clamped PN techniques.
[Show abstract][Hide abstract] ABSTRACT: To facilitate robotic nerve-sparing radical prostatectomy, we developed a novel three dimensional (3D) surgical navigation model which is displayed on the Tile-Pro function of the da Vinci® surgeon console. Based on 3-D trans-rectal ultrasound (TRUS)-guided prostate biopsies (Urostation®, Koelis), we reconstructed a 3-D model of the TRUS-visible, histologically-confirmed 'index' cancer lesion in 10 consecutive patients. Five key anatomic structures (prostate, image-visible biopsy-proven 'index' cancer lesion, neurovascular bundles, urethra, and recorded biopsy trajectories) were image-fused and displayed onto the Tile-Pro function of the robotic console. 3D model facilitated careful surgical dissection in the vicinity of the biopsy-proven 'index' lesion. Geographic location of the 'index lesion' on final histology correlated with the software-created 3D model. Negative surgical margins were achieved in 90%, except for one case with extensive extra-prostate extension. At post-operative 3 months, PSA were undetectable (<0.03 ng/ml) in all cases. The initial experience of the navigation model is presented.
Journal of endourology / Endourological Society 01/2014; · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Intraoperative transrectal ultrasonography during laparoscopic radical prostatectomy has been reported to lead to a reduction in surgical margin rates. However, the use of a surgeon-controlled ultrasound probe that allows for precise manipulation and direct interpretation of the image by a console surgeon has yet to be studied. The aim of the present study was to show initial feasibility using the microtransducer with 9-mm scan length controlled by the console surgeon during robot-assisted radical prostatectomy in 10 patients. The transducer is designed as a drop-in probe with a flexible cord for insertion through a laparoscopic port, and is controlled by a robotic arm with the ultrasonographic image shown as a console Tile-pro display. Intraoperative localization of the biopsy-proven cancerous hypoechoic lesion was feasible in four out of four cases. The microtransducer facilitated identification of the bladder neck as well as the appropriate level of neurovascular bundle release. Negative surgical margin was achieved in all 10 cases (100%), even though five of 10 patients (50%) had extraprostatic (pT3) disease. Recovery of erectile function and continence was encouraging. In conclusion, intraoperative ultrasound navigation using a drop-type microtransducer is a novel technique that could enhance the incremental value of the standard information.
International Journal of Urology 01/2014; · 1.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Despite significant developments in transurethral surgery for benign prostatic hyperplasia (BPH), simple prostatectomy remains an excellent option for patients with large glands.
To describe our technique of transvesical robotic simple prostatectomy (RSP).
From May 2011 to April 2013, 25 patients underwent RSP.
We performed RSP using our technique.
Baseline demographics, pathology data, perioperative complications, 90-d complications, and functional outcomes were assessed.
Mean patient age was 72.9 yr (range: 54-88), baseline International Prostate Symptom Score (IPSS) was 23.9 (range: 9-35), prostate volume was 149.6ml (range: 91-260), postvoid residual (PVR) was 208.1ml (range: 72-800), maximum flow rate (Qmax) was 11.3ml/s, and preoperative prostate-specific antigen was 9.4 ng/ml (range: 1.9-56.3). Eight patients were catheter dependent before surgery. Mean operative time was 214min (range: 165-345), estimated blood loss was 143ml (range: 50-350), and the hospital stay was 4 d (range: 2-8). There were no intraoperative complications and no conversions to open surgery. Five patients had a concomitant robotic procedure performed. Early functional outcomes demonstrated significant improvement from baseline with an 85% reduction in mean IPSS (p<0.0001), an 82.2% reduction in mean PVR (p=0.014), and a 77% increase in mean Qmax (p=0.20). This study is limited by small sample size and short follow-up period. One patient had a urinary tract infection; two had recurrent hematuria, one requiring transfusion; one patient had clot retention and extravasation, requiring reoperation.
Our technique of RSP is safe and effective. Good functional outcomes suggest it is a viable option for BPH and larger glands and can be used for patients requiring concomitant procedures.
We describe the technique and report the initial results of a series of cases of transvesical robotic simple prostatectomy. The procedure is both feasible and safe and a good option for benign prostatic hyperplasia with larger glands.
[Show abstract][Hide abstract] ABSTRACT: The present consensus panel convened to discuss the use of renal mass biopsy (RMB) for small renal masses, formulate technical aspects, outline potential pitfalls and provide recommendations for the practicing clinician.
The meeting was conducted as an informal consensus process and no scoring system was used to measure the levels of agreement on the different topics. A moderated general discussion was used as the basis for consensus and arising issues were resolved at this point. A consensus was established and lack of agreement to topics or specific items was noted at this point.
Recommended biopsy technique: at least 2 cores, sampling different tumor regions with ultrasonography being the preferred method of image guidance. Pathological interpretation: "non-diagnostic samples" should refer to insufficient material, inconclusive and normal renal parenchyma. For non-diagnostic samples, a repeat biopsy is recommended. Fine needle aspiration may provide additional information but cannot substitute for core biopsy. Indications for RMB: biopsy is recommended in most cases except in patients with imaging or clinical characteristics indicative of pathology (syndromes, imaging characteristics) and cases whereby conservative management is not contemplated. RMB is recommended for active surveillance but not for watchful waiting candidates.
We report the results of an international consensus meeting on the use of renal mass biopsy for small renal masses, defining the technique, pathological interpretation and indications.
[Show abstract][Hide abstract] ABSTRACT: Objective: To describe a technique to manage large intravesical prostate lobes (IVPL) during robot-assisted radical prostatectomy (RARP). Methods: We used a "rescue stitch" to retract large IVPLs anteriorly out of the bladder lumen. This stitch is a 6-inch long 0-vicryl suture on a CT-1 needle with a Hem-o-lok clip tied to the tail end. We deployed this through the IVPL from distal to proximal allowing the Hem-o-lok clip to sit against the lobe's distal aspect. The suture is grasped and pulled toward the symphysis, delivering the IVPL from the bladder lumen providing an unobstructed view of the posterior bladder neck (BN). Results: This was performed in 15 patients. Median (range) time to prepare and deploy the stitch(es) was 2 (0.5-3) and 5 (2-15) minutes, respectively. Five patients required >1 stitch. BN reconstruction was not required. No patient had positive margin at the BN. Conclusions: Deploying a stitch allows anterior dynamic retraction of the prostate, facilitating the dissection of the posterior BN.
Journal of endourology / Endourological Society 07/2013; · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PURPOSE OF REVIEW: Radical prostatectomy, regardless of the technology used intraoperatively, induces erectile dysfunction for most men who undergo the procedure. For many men, this proves to be transient. Penile rehabilitation strategies have been developed with the goal of increasing the probability and speed of return of sexual function. The purpose of this work is to review the fundamentals of erectile dysfunction relevant to the postprostatectomy patient as well as the components that are often included in penile rehabilitation strategies. RECENT FINDINGS: Preservation of smooth muscle tissue is the key to preserving erectile function. This can be accomplished by providing the penis with regular exposure to oxygenated blood through intracaversonal injection therapy or vacuum erection device therapy. Dietary supplementation aimed to increase the nitric oxide production can also be beneficial. As well, chronic administration of PDE5 inhibitors may also help maintain the smooth muscle/collagen ratio in the corporal tissue. SUMMARY: These findings have led to the development of our management model that includes daily vacuum erection device therapy, dietary supplementation and PDE5 inhibitors which is described in detail. The success of any rehabilitation strategy is dependent on the patient compliance which needs to be facilitated by care-giver encouragement and the setting of realistic expectations.
Current opinion in urology 01/2013; · 2.50 Impact Factor