Ari Bergman

The da vinci robot system eliminates multispecialty surgical trainees' hand dominance in open and robotic surgical settings.

Background and Objectives: Handedness, or the inherent dominance of one hands dexterity over the others, is a factor in open surgery but has an unknown importance in robot-assisted surgery. We sought to examine whether the robotic surgery platform could eliminate the effect of inherent hand preference. Methods: Residents from the Urology and Obstetrics/Gynecology departments were enrolled. Ambidextrous and left-handed subjects were excluded. After completing a questionnaire, subjects performed three tasks modified from the Fundamentals of Laparoscopic Surgery curriculum. Tasks were performed by hand and then with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, California). Participants were randomized to begin with using either the left or the right hand, and then switch. Left:right ratios were calculated from scores based on time to task completion. Linear regression analysis was used to determine the significance of the impact of surgical technique on hand dominance. Results: Ten subjects were enrolled. The mean difference in raw score performance between the right and left hands was 12.5 seconds for open tasks and 8 seconds for robotic tasks (P < .05). Overall left-right ratios were found to be 1.45 versus 1.12 for the open and robot tasks, respectively (P < .05). Handedness significantly differed between robotic and open approaches for raw time scores (P < .0001) and left-right ratio (P = .03) when controlling for the prior tasks completed, starting hand, prior robotic experience, and comfort level. These findings remain to be validated in larger cohorts. Conclusion: The robotic technique reduces hand dominance in surgical trainees across all task domains. This finding contributes to the known advantages of robotic surgery.

A Pilot Study of Laparoscopic Doppler Ultrasound Probe to Map Arterial Vascular Flow within the Neurovascular Bundle during Robot-Assisted Radical Prostatectomy

Purpose. To report on the feasibility of a new Laparoscopic Doppler ultrasound (LDU) technology to aid in identifying and preserving arterial blood flow within the neurovascular bundle (NVB) during robotic prostatectomy (RARP). Materials and Methods. Nine patients with normal preoperative potency and scheduled for a bilateral nerve-sparing procedure were prospectively enrolled. LDU was used to measure arterial flow at 6 anatomic locations alongside the prostate, and signal intensity was evaluated by 4 independent reviewers. Measurements were made before and after NVB dissection. Modifications in nerve-sparing procedure due to LDU use were recorded. Postoperative erectile function was assessed. Fleiss Kappa statistic was used to evaluate inter-rater agreement for each of the 12 measurements. Results. Analysis of Doppler signal intensity showed maintenance of flow in 80% of points assessed, a decrease in 16%, and an increase in 4%. Plane of NVB dissection was altered in 5 patients (56%) on the left and in 4 patients (44%) on the right. There was good inter-rater reliability for the 4 reviewers. Use of the probe did not significantly increase operative time or result in any complications. Seven (78%) patients had recovery of erections at time of the 8-month follow-up visit. Conclusions. LDU is a safe, easy to use, and effective method to identify local vasculature and anatomic landmarks during RARP, and can potentially be used to achieve greater nerve preservation.

Comparison of Robot-Assisted and Open Retropubic Radical Prostatectomy for Risk of Biochemical Progression in Men with Positive Surgical Margins

OBJECTIVE Robot-assisted radical prostatectomy (RARP) is a minimally invasive alternative to open retropubic radical prostatectomy (RP), and is reported to offer equivalent oncologic outcomes while reducing perioperative morbidity. However, the technique of extirpation can differ based on the usage of thermal energy and coagulation during RARP, which may alter the risk of finding a positive surgical margin (PSM) as cautery may destroy residual cancer cells. We sought to evaluate whether the method of surgery (RP vs RARP) affects the rate of biochemical recurrence (BCR) in patients with PSMs. MATERIALS & METHODS The Columbia University Urologic Oncology Database was reviewed to identify patients who underwent RP and RARP from 2000 to 2010 and had a PSM on final pathology. BCR was defined as a postoperative prostate-specific antigen (PSA) ≥0.2 ng/mL. The Kaplan-Meier analysis was utilized to calculate BCR rates based on the method of surgery. Cox regression analysis was performed to determine if the method of surgery was associated with BCR. RESULTS We identified 3267 patients who underwent prostatectomy, of which 910 (28%) had a PSM. Of those with a PSM, 337 patients had available follow-up data, including 229 who underwent RP (68%) and 108 who underwent RARP (32%). At a mean follow-up time of 37 months for the RP group, 103 (46%) patients demonstrated BCR; at a mean follow-up time of 44 months for the RARP group, 62 (57%) patients had a BCR (p=0.140). Two-year BCR-free rates for RP vs RARP were 65% and 49%, respectively (log-rank p<0.001). However, after controlling for age, PSA, grade, and year of surgery, the surgical method was not significantly associated with increased risk of BCR (HR 1.25; p=0.29). CONCLUSION Our results confirm the noninferiority of RARP to RP with regard to patients with PSMs. As such, all patients with a PSM at RP are at high risk for BCR and should be followed in the same manner regardless of the surgical approach.

Baseline Serum 25-Hydroxyvitamin D Levels in Men Undergoing Radical Prostatectomy: Is There An Association With Adverse Pathologic Features?

INTRODUCTION/BACKGROUND The purpose of this study was to evaluate the prevalence of vitamin D (VitD) deficiency in men undergoing radical prostatectomy and determine whether an association exists between preoperative VitD levels and adverse pathologic features. PATIENTS AND METHODS Patients scheduled to undergo radical prostatectomy for clinically localized disease from January to August 2012 were prospectively followed and those with available preoperative serum 25-hydroxyvitamin D levels were included. Men with a known diagnosis of VitD deficiency or taking VitD supplementation were excluded. Cox regression analysis was performed to determine whether preoperative VitD level is predictive of adverse pathologic outcomes. RESULTS One hundred consecutive men were included. Mean age was 62 (range, 42-79) years and mean VitD level was 26 (range, 6-57) ng/mL. Overall, 65 men (65%) had suboptimal levels of VitD (< 30 ng/mL), and 32 (32%) had deficiency (< 20 ng/mL). There was no significant correlation between VitD and age (P = .5). In logistic regression analysis, VitD level was not predictive of pathologic Gleason (P = .11), pathologic stage (P = .7), or positive margin status (P = .8). CONCLUSION The association between VitD and prostate cancer has been controversial and data suggesting an increased risk of aggressive cancer in men with low levels of VitD have been inconsistent. We found that baseline preoperative VitD level was not associated with any adverse pathologic features. However, VitD deficiency is a common finding in this population, although unrelated to patient age. These results represent the first time the correlation between VitD and prostate cancer has been evaluated in a cohort of men undergoing radical prostatectomy.

Pharmacotherapy for Nocturia

This chapter presents the current state of knowledge of the pharmacotherapy of nocturia. An overview of the diagnostic evaluation is followed by discussion of the indications and efficacy of different classes of medications used to treat nocturia. Nocturia, defined as voiding that occurs during the hours of sleep, is common and bothersome. The underlying causes are multiple and diverse. Determining the underlying etiology is essential for choosing the appropriate therapy. Pharmacologic treatment should be guided by a thorough clinical evaluation and data derived from a frequency-volume chart. Possible medications include those for overactive bladder (OAB), those for benign prostatic hyperplasia, and those to reduce nocturnal urine production. A systematic approach is essential for the optimal treatment of nocturia. In the absence of nocturnal polyuria, medications for BPH or overactive bladder may be employed. NP is highly prevalent among patients with nocturia, however, and antidiuretic therapy should be considered when measures to address serious underlying etiologic conditions are ineffective.

1406 DOUBLE BLINDED RANDOMIZED PLACEBO CONTROLLED TRIAL TO DETERMINE EFFECT OF BUPIVACAINE DORSAL PENILE BLOCK ON POSTOPERATIVE PAIN AND FOLEY DISCOMFORT FOLLOWING ROBOTIC ASSISTED RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVES: Urethral catheterization is a source of significant discomfort and pain after Robotic Assisted Radical Prostatectomy (RARP). Herein we present an interim analysis of a study assessing the effect of Bupivacaine dorsal penile block on postoperative pain after RARP. METHODS: Between December 2011 and October 2012 at total of 78 patients were enrolled in a prospective double blinded randomized placebo controlled study comparing bupivacaine (20cc at 0.5%) dorsal penile block injection versus normal saline injection at the conclusion of RARP. Postoperative pain and urinary symptoms were evaluated using questionnaires based on visual analog scales at multiple time points until Foley removal. In addition, patients were required to maintain a log of narcotic and pain medication use after RARP until Foley catheter removal. Student?s t test and Fisher?s exact tests were used for continuous parametric and categorical data, respectively, with p 0.05 considered to be significant. RESULTS: No complications or adverse events occurred in this study. There was no difference with respect to age, pre-operative PSA, stage, Gleason score, body mass index, operative time or history of diabetes between the two groups. There was a trend toward less inpatient narcotic use in patients receiving block vs. placebo (3.9 mg vs. 5.7 mg morphine equivalents, p .19). Outpatient narcotic use was similarly less in the patients receiving block vs. placebo (13.8 mg vs. 15mg morphine equivalents, p .77). With respect to abdominal incisional pain and bladder spasm discomfort, there was no significant difference at the 18 hour time point (average discharge time) or at the end of the follow up period on day 9. At the 18 hour time point period patients receiving penile block reported significantly less penile pain than patients receiving saline injection (1.39 vs. 2.0, p .04). At the end of the follow up period this difference remained significant in favor of penile block (.75 vs. 3.27, p .04). CONCLUSIONS: In this interim analysis, penile block with bupivacaine appears to improve penile pain score postoperatively after RARP. These results suggest that initial post-operative pain management may affect the perception of pain going forward. Further confirmation is needed to standardize penile block as a viable protocol to manage post-operative Foley discomfort after RARP.