David D. Thiel

Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European-American Multi-institutional Analysis

BACKGROUND Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique. OBJECTIVE To report a large multi-institutional series of minimally invasive SP (MISP). DESIGN, SETTING, AND PARTICIPANTS Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis. INTERVENTION Laparoscopic or robotic SP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score <8, maximum flow rate >15ml/s, and no perioperative complications. RESULTS AND LIMITATIONS Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100ml (range: 89-128). Median estimated blood loss was 200ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p=0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p=0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss (p=0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. CONCLUSIONS This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications. PATIENT SUMMARY Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.

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

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

Robotics in urology: past, present, and future.

The modern-day urologist is continually armed with new instruments and technology aimed at decreasing the overall invasiveness of urologic procedures. Robotic technology is aimed at improving clinical outcomes by correcting human technical inadequacies such as hand tremors and imprecise suturing. The first reported use of robotics to assist with surgery was in 1985, and the first use of robotics in urology was published in 1989. The currently utilized master-slave system (da Vinci Robotic Platform), Intuitive Surgical, Sunnyvale, CA) has popularized robotic surgery for use in numerous urologic conditions including prostate cancer, bladder cancer, renal cancer, uretero-pelvic junction obstruction, and pelvic prolapse. New developments in robotic technology may revolutionize many other aspects of urology including percutaneous renal access and rounding on patients after surgery. This review provides a brief overview of the history of robotics in urology, a description of the da Vinci surgical system and its current utilization as well as limitations, and a review of evolving robotic technology in the field of urology.

Cost Analysis of Open Radical Cystectomy Versus Robot-assisted Radical Cystectomy

Bladder cancer is the fourth and ninth most common malignancy in males and females, respectively, in the U.S. and one of the most costly cancers to manage. With the current economic condition, physicians will need to become more aware of cost-effective therapies for the treatment of various malignancies. Robot-assisted radical cystectomy (RARC) is the latest minimally invasive surgical option for muscle-invasive bladder cancer. Current reports have shown less blood loss, a shorter hospital stay, and a lower morbidity with RARC, as compared with the traditional open radical cystectomy (ORC), although long-term oncologic results of RARC are still maturing. There are few studies that have assessed the cost outcomes of RARC as compared with ORC. Currently, ORC appears to offer a direct cost advantage due to the high purchase and maintenance cost of the robotic platform, although when the indirect costs of complications and extended hospital stay with ORC are considered, RARC may be less expensive than the traditional open procedure. In order to accurately evaluate the cost effectiveness of RARC versus ORC, prospective randomized trials between the two surgical techniques with long-term oncologic efficacy are needed.

In Vivo Comparison of Radiation Exposure of Dual-Energy CT Versus Low-Dose CT Versus Standard CT for Imaging Urinary Calculi

PURPOSE Dual-energy computed tomography (DECT) is an emerging imaging modality with the unique capability of determining urinary stone composition. This study compares radiation exposure of DECT, standard single-energy CT (SECT), and low-dose renal stone protocol single-energy CT (LDSECT) for the evaluation of nephrolithiasis in a single in vivo patient cohort. MATERIALS AND METHODS Following institutional review board (IRB) approval, we retrospectively reviewed 200 consecutive DECT examinations performed on patients with suspected urolithiasis over a 6-month period. Of these, 35 patients had undergone examination with our LDSECT protocol, and 30 patients had undergone examination of the abdomen and pelvis with our SECT imaging protocol within 2 years of the DECT examination. The CT dose index volume (CTDIvol) was used to compare radiation exposure between scans. Image quality was objectively evaluated by comparing image noise. Statistical evaluation was performed using a Students t-test. RESULTS DECT performed at 80/140 kVp and 100/140 kVp did not produce a significant difference in radiation exposure compared with LDSECT (p=0.09 and 0.18, respectively). DECT performed at 80/140 kVp and 100/140 kVp produced an average 40% and 31%, respectively, reduction in radiation exposure compared with SECT (p<0.001). For patients imaged with the 100/140 kVp protocol, average values for images noise were higher in the LDSECT images compared with DECT images (p<0.001) and there was no significant difference in image noise between DECT and SECT images in the same patient (p=0.88). Patients imaged with the 80/140 kVp protocol had equivocal image noise compared with LDSECT images (p=0.44), however, DECT images had greater noise compared with SECT images in the same patient (p<0.001). Of the 75 patients included in the study, stone material was available for 16; DECT analysis correctly predicted stone composition in 15/16 patients (93%). CONCLUSION DECT provides knowledge of stone composition in addition to the anatomic information provided by LDSECT/SECT without increasing patient radiation exposure and with minimal impact on image noise.

Evaluation of the association of prostate cancer‐specific anxiety with sexual function, depression and cancer aggressiveness in men 1 year following surgical treatment for localized prostate cancer

Cancer‐specific anxiety (CSA) can affect treatment decisions and is common in men following surgery for prostate cancer (PCa). We hypothesized that CSA is also associated with factors affecting quality of life. Herein, we examine the association of CSA with psychosocial factors and PCa aggressiveness in a cohort of men 1 year after prostatectomy for localized PCa.

Three‐dimensional tumour volume and cancer‐specific survival for patients undergoing nephrectomy to treat pT1 clear‐cell renal cell carcinoma

Study Type – Prognosis (case series)

Simulation-Based Training for Bedside Assistants Can Benefit Experienced Robotic Prostatectomy Teams

PURPOSE We designed a three-phase bedside assistant training course for those involved with robot-assisted radical prostatectomy (RARP). We also examined whether an experienced RARP team (>1000 cases) would perceive benefit from this three-phase bedside assistant training course. MATERIALS AND METHODS The 13 RARP bedside assistants were identified at our institution (three surgical technicians, two surgical assistants, four resident trainees, and four physician assistants). The course consisted of three phases that were taught at three separate morning sessions. Phase 1 focused on robot functionality. Phase 2 consisted of a step-by-step video session that focused on the assistants role in each RARP step. Phase 3 involved three hands-on laparoscopic drills that were to be completed in a predetermined period. Pre- and postcourse questionnaires assessed learner knowledge pertaining to RARP. RESULTS All 13 learners completed the three-phase training course. Nine of 13 learners thought this course would be beneficial, although, 9 of 13 already thought that they were good RARP assistants before the course. Ten of 13 learners were able to complete the hands-on drills in the predetermined periods. On completion of the course, every learner thought the course was beneficial and that it should be repeated annually. Twelve of 13 thought that the course made them a better assistant and that their intra-abdominal spatial orientation was greatly improved. Seven of the learners thought the hands-on drills were the most beneficial portion of the course, while the other six found the step-by-step lecture the most beneficial. CONCLUSIONS A three-phase hands-on RARP bedside assistant training course is beneficial to and desired by an experienced RARP team at least annually.

Robotic-assisted Bladder Diverticulectomy: Tips and Tricks

INTRODUCTION The da Vinci Surgical System has become extremely popular in the field of urology for procedures requiring complex reconstructive maneuvers, such as radical prostatectomy and pyeloplasty. A natural extension of these procedures is the use of the da Vinci system for complex urinary tract reconstruction deep in the pelvis, such as bladder diverticulectomy. TECHNICAL CONSIDERATIONS In our report and accompanying Video, we have demonstrated some technical tips and tricks with regard to patient selection, preoperative imaging, patient positioning, port placement, intraoperative diverticulum recognition/excision, and cystotomy repair that the surgeon might find beneficial for successful completion of robotic-assisted bladder diverticulectomy. CONCLUSIONS The tips and tricks we have presented might aid in the successful completion of robotic bladder diverticulectomy.

Botulinum A Toxin/Dimethyl Sulfoxide Bladder Instillations for Women With Refractory Idiopathic Detrusor Overactivity: A Phase 1/2 Study

We completed a phase 1/2 trial to evaluate the safety and potential efficacy of direct intravesical instillation of a botulinum type A toxin/dimethyl sulfoxide (DMSO) solution for treatment of idiopathic detrusor overactivity in women. Twenty-five women with medication-resistant, urodynamic-confirmed idiopathic detrusor overactivity were enrolled. A total of 9 patients were treated in phase 1 of the study. Three patients were given a 66% dosing of solution; 22 patients received the full 300 units of botulinum toxin and 50 mL of DMSO (50% concentration). Adverse effects, 24-hour pad weights, episodes of incontinence, postvoid residuals, and scores on the Blaivas-Groutz anti-incontinence scale, Indevus Urgency Severity Scale, Incontinence Impact Questionnaire-short form, and Urogenital Distress Inventory (6 items) questionnaire were recorded at baseline, 1 month, and 3 months after instillation. No serious adverse effects or clinically important increases in postvoid residual occurred. Among the 21 women who completed phase 2 of the study, the median number of incontinent episodes decreased from 4 at baseline to 2 at 1 month ( P =.004) and increased to 4 at 3 months ( P =.81). Median scores improved from baseline to 1 month on the Incontinence Impact Questionnaire (from 13 to 7; P =.007) and Urogenital Distress Inventory (from 10 to 5; P =.003). Although 11 women (52%) reported severe urgency based on the Indevus Urgency Severity Scale at baseline, only 1 (5%; P P =.004) women reported severe scores at 1 and 3 months, respectively. Direct instillation of botulinum toxin/DMSO solution is safe. Its promising clinical effect warrants further evaluation in a randomized, placebo-controlled phase 3 setting.