Ananthakrishnan Sivaraman

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

Study Type – Therapy (case series)
Level of Evidence 4

Anatomic Grading of Nerve Sparing During Robot-Assisted Radical Prostatectomy

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.

Factors Affecting Return of Continence 3 Months After Robot-Assisted Radical Prostatectomy: Analysis From a Large, Prospective Data by a Single Surgeon

PURPOSE In this study we identified preoperative or intraoperative factors responsible for the early return of continence after robot-assisted radical prostatectomy using data from a high volume center. MATERIALS AND METHODS Data from 1,299 patients who underwent robot-assisted radical prostatectomy performed by a single surgeon from January 2008 to June 2010 were collected prospectively and analyzed retrospectively. Patients were categorized according to whether they regained continence (no pad and no urinary leakage) within 3 months and variables were then compared. A self-administered validated questionnaire (Expanded Prostate Cancer Index Composite) was used for assessment of continence status and time to recovery. RESULTS Within 3 months after surgery 86.3% of patients (1,121/1,299) had recovered continence. Multivariable Cox regression analysis revealed that only age (p <0.001, hazard ratio 0.98, 95% CI 0.97-0.99) and performance of a nerve sparing procedure were independent predictors. After adjusting for age, the hazard ratio was 1.61 (95% CI 1.25-2.07, p <0.001) for partial nerve sparing and 1.44 (1.13-1.83, p = 0.003) for bilateral nerve sparing compared to the nonnerve sparing group. Median time (95% CI) to the recovery of continence was prolonged in the nonnerve sparing group compared to nerve sparing counterparts at 6 (5.12-6.88), 4 (3.60-4.40) and 5 weeks (4.70-5.30) in the nonnerve sparing, partial nerve sparing and bilateral nerve sparing groups, respectively, with log rank p <0.01. CONCLUSIONS Findings from our analysis indicate that the likelihood of postoperative urinary control was significantly higher in younger patients and when a nerve sparing procedure was performed.

Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-urethral anastomosis

Study Type – Therapy (case series)

The Role of the Prostatic Vasculature as a Landmark for Nerve Sparing During Robot-Assisted Radical Prostatectomy

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) mm2 versus14 (9-25) mm2; 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.

Critical review of ' pentafecta ' outcomes after robot-assisted laparoscopic prostatectomy in high-volume centres

Whats known on the subject? and What does the study add?

Robot-assisted Laparoscopic Dismembered Pyeloplasty for Ureteropelvic Junction Obstruction: A Multi-institutional Experience

OBJECTIVE To report a 6-year multi-institutional experience and outcomes with robot-assisted laparoscopic pyeloplasty (RLP) for the repair of ureteropelvic junction obstruction (UPJO). PATIENTS AND METHODS Between June 2002 and October 2008, 168 adult patients from 3 institutions underwent RLP for UPJO. A retrospective analysis of prospectively collected data were performed after institutional review board approval. Diagnosis was by intravenous urogram or computed tomography scan and diuretic renogram. All patients underwent RLP through a 4-port laparoscopic technique. Demographic, preoperative, operative, and postoperative endpoints for primary and secondary repair of UPJO were measured. Success was defined as a T½ of <20 minutes on diuretic renogram and symptom resolution. Pain resolution was assessed by subjective patient reports. RESULTS Of 168 patients, 147 (87.5%) had primary repairs and 21 (12.5%) had secondary repairs. Of the secondary repairs, 57% had a crossing vessel etiology. Mean operative time was 134.9 minutes, estimated blood loss was 49 mL, and length of stay was 1.5 days. Mean follow-up was 39 months. Overall, 97.6% of patients had a successful outcome, with a 6.6% overall complication rate. CONCLUSIONS To our knowledge, this review represents the largest multi-institutional experience of RLP with intermediate-term follow-up. RLP is a safe, efficacious, and viable option for either primary or secondary repair of UPJO with reproducible outcomes, a high success rate, and a low incidence of complications.

Retrograde versus antegrade nerve sparing during robot-assisted radical prostatectomy: which is better for achieving early functional recovery?

BACKGROUND Although the retrograde approach to nerve sparing (NS) aimed at maximizing NS during robot-assisted radical prostatectomy (RARP) has been described, its significant benefits compared to the antegrade approach have not yet been investigated. OBJECTIVE To evaluate the impact of NS approaches on perioperative, pathologic, and functional outcomes. DESIGN, SETTING, AND PARTICIPANTS Five hundred one potent (Sexual Health Inventory for Men [SHIM] score >21) men underwent bilateral full NS and were followed up for a minimum of 1 yr. After propensity score matching, 344 patients were selected and were then categorized into two groups. SURGICAL PROCEDURE RARP with antegrade NS (n=172) or RARP with retrograde NS (n=172). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Functional outcomes were assessed using validated questionnaires. Multivariable logistic regression models were applied. RESULTS AND LIMITATIONS Positive margin rates were similar (11.1% vs 6.9%; p=0.192), and no correlation with the NS approach was found on regression analysis. At 3, 6, and 9 mo, the potency rate was significantly higher in the retrograde approach (65% vs 80.8% and 72.1% vs 90.1% and 85.3% vs 92.9%, respectively). The multivariable model indicated that the NS approach was an independent predictor for potency recovery at 3, 6, and 9 mo, along with age, gland size, and hyperlipidemia. After adjusting for these predictors, the hazard ratio (HR) for the retrograde relative to the antegrade approach was 2.462 (95% confidence interval [CI], 1.482-4.089; p=0.001) at 3, 4.024 (95% CI, 2.171-7.457; p<0.001) at 6, and 2.145 (95% CI, 1.019-4.514; p=0.044) at 9 mo. Regarding continence, the recovery rates at each time point and the mean time to regaining it were similar, and the method of NS had no effect on multivariable analysis. The absence of randomization is a major limitation of this study. CONCLUSIONS In patients with normal erectile function who underwent bilateral full NS, a retrograde NS approach facilitated early recovery of potency compared to that with an antegrade NS approach without compromising cancer control.

Cirugía robótica: Historia e impacto en la enseñanza

CONTEXT The purpose of this article is to review the history of robotic surgery, its impact on teaching as well as a description of historical and current robots used in the medical arena. SUMMARY OF EVIDENCE Although the history of robots dates back to 2000 years or more, the last two decades have seen an outstanding revolution in medicine, due to all the changes that robotic surgery has made in the way of performing, teaching and practicing surgery. CONCLUSIONS Robotic surgery has evolved into a complete and self-contained field, with enormous potential for future development. The results to date have shown that this technology is capable of providing good outcomes and quality care for patients.

Cavernosal Nerve Preservation During Robot-assisted Radical Prostatectomy Is a Graded Rather Than an All-or-none Phenomenon: Objective Demonstration by Assessment of Residual Nerve Tissue on Surgical Specimens

OBJECTIVE To demonstrate the existence of different degrees of nerve sparing (NS) (graded NS) by comparing the surgeons intent of NS with the residual nerve tissue on prostatectomy specimens. METHODS We performed a prospective study of 133 consecutive patients who underwent robot-assisted radical prostatectomy in January and February of 2011. The surgeon graded the amount of NS intraoperatively independently for either side as follows: 1, no NS; 2, <50% NS; 3, 50% NS; 4, 75% NS; and 5, ≥ 95% NS. A pathologist who was unaware of the surgeons score measured the area of residual nerve tissue on the posterolateral surface of the prostate. RESULTS A greater NS score correlated significantly with a decreasing area of residual nerve tissue on the prostatectomy specimens (P < .001). Overall, the area of residual nerve tissue on the prostatectomy specimens was significantly different among the NS groups (P < .001). On specific intergroup analysis, significant differences were found in the area of residual nerve tissue on the prostatectomy specimens between the greater NS groups: NS score 3 versus 4, median 13 mm(2) (interquartile range [IQR] 7-23) versus 3 mm(2) (IQR 0-8; P = .01); NS score 4 versus 5, median 3 mm(2) (IQR 0-8) versus 0.5 mm(2) (IQR 0-2; P = .001). CONCLUSION Subjective NS classification using the surgeons intraoperative perception correlated significantly with the area of residual nerve tissue on the prostatectomy specimens determined by the pathologist. It is possible to intentionally tailor the amount of NS performed at surgery. This finding demonstrates that NS is a graded rather than an all-or-none phenomenon that can even go beyond the traditional concept of complete, partial, or no NS.