Elena Ortiz Oshiro

Long-term outcomes after robotic sacrocolpopexy in pelvic organ prolapse: prospective analysis.

OBJECTIVE To evaluate the feasibility and long-term outcomes of our initial series of robot-assisted laparoscopic sacrocolpopexy. METHODS We conducted a prospective analysis of our series of robotic sacrocolpopexy. INCLUSION CRITERIA patients with grades III and IV cystocele and or other symptomatic pelvic organ prolapse. We performed a transperitoneal four-trocar technique with the Da Vinci robotic system using two polypropylene meshes for fixation to the sacral promontory. The primary outcome was recurrence; secondary outcomes included operating room time, blood loss, conversion to open surgery, complications and length of stay. RESULTS 31 consecutive procedures were included. Mean patient age was 65.2 (50-81) years. Mean operating room time was 186 (150-230) min. We converted 1 case to laparoscopy (3.2%). There were two major complications (1 acute myocardial infarction and 1 reoperation for excess tension with syncopes), two minor complications (1 wound infection and 1 ileus) and no recurrences at a mean follow-up of 24.5 (16-33) months. CONCLUSIONS Robotic sacrocolpopexy could possibly improve with experience after overcoming the learning curve. There is no doubt it is a reproducible technique, but its safety and efficacy still need to be proven. Our initial series demonstrated good outcomes and no recurrences at 24.5 months of follow-up.Objective: To evaluate the feasibility and long-term outcomes of our initial series of robot-assisted laparoscopic sacrocolpopexy. Methods: We conducted a prospective analysis of our series of robotic sacrocolpopexy. Inclusion criteria: patients with grades III and IV cystocele and or other symptomatic pelvic organ prolapse. We performed a transperitoneal four-trocar technique with the Da Vinci robotic system using two polypropylene meshes for fixation to the sacral promontory. The primary outcome was recurrence; secondary outcomes included operating room time, blood loss, conversion to open surgery, complications and length of stay. Results: 31 consecutive procedures were included. Mean patient age was 65.2 (50–81) years. Mean operating room time was 186 (150–230) min. We converted 1 case to laparoscopy (3.2%). There were two major complications (1 acute myocardial infarction and 1 reoperation for excess tension with syncopes), two minor complications (1 wound infection and 1 ileus) and no recurrences at a mean follow-up of 24.5 (16–33) months. Conclusions: Robotic sacrocolpopexy could possibly improve with experience after overcoming the learning curve. There is no doubt it is a reproducible technique, but its safety and efficacy still need to be proven. Our initial series demonstrated good outcomes and no recurrences at 24.5 months of follow-up.

Colposacropexia laparoscópica asistida por robot como tratamiento del prolapso urogenital

Laparoscopic colposacropexy has become a substitute for open surgery in the treatment of pelvic organ prolapse. In the same way, robotic assisted surgery is a new step in the evolution of the procedure. In this paper we intend to show our surgical technique and preliminary results. From November 2006 to date, 10 patients have undergone this procedure at the Hospital Clinico San Carlos. The main indication for the operation was existence of symptomatic pelvic prolapse. Both patients with or without hysterectomy have been operated, without making significant differences between them. Preoperative evaluation workout included: cystogram, urinary tract ultrasound and urodynamics in all cases; urinary tract MRI was performed only in selected cases. All patients underwent surgery under general anesthesia, with at least three robotic trocars (8 mm) and one conventional trocar for the assistant; 2 accessory trocars were necessary in some cases, mainly at the beginning of the series. Most procedures in our series were associated with a transobturator suburethral sling for the treatment of stress urinary incontinence or prevention of its appearance after prolapse repair. Our results are comparable to those reported in other larger series in terms of operative time, hospital stay and early or late complications. Pending an evaluation on the long term with larger series, we can include robot assisted colposacropexy among the therapeutic options for symptomatic pelvic floor prolapse repair.Laparoscopic colposacropexy has become a substitute for open surgery in the treatment of pelvic organ prolapse. In the same way, robotic assisted surgery is a new step in the evolution of the procedure. In this paper we intend to show our surgical technique and preliminary results. From November 2006 to date, 10 patients have undergone this procedure at the Hospital Clinico San Carlos. The main indication for the operation was existence of symptomatic pelvic prolapse. Both patients with or without hysterectomy have been operated, without making significant differences between them. Preoperative evaluation workout included: cystogram, urinary tract ultrasound and urodynamics in all cases; urinary tract MRI was performed only in selected cases. All patients underwent surgery under general anesthesia, with at least three robotic trocars (8 mm) and one conventional trocar for the assistant; 2 accessory trocars were necessary in some cases, mainly at the beginning of the series. Most procedures in our series were associated with a transobturator suburethral sling for the treatment of stress urinary incontinence or prevention of its appearance after prolapse repair. Our results are comparable to those reported in other larger series in terms of operative time, hospital stay and early or late complications. Pending an evaluation on the long term with larger series, we can include robot assisted colposacropexy among the therapeutic options for symptomatic pelvic floor prolapse repair.OBJETIVOS La colposacropexia laparoscopica es una tecnica que ha venido a sustituir a la cirugia abierta para el tratamiento de los prolapsos del suelo pelvico. De la misma manera, la cirugia asistida por robot supone un nuevo paso en la evolucion de la tecnica. En este articulo pretendemos mostrar, tanto nuestra tecnica quirurgica como los resultados preliminares obtenidos con la misma. En el Hospital Clinico San Carlos han sido intervenidas con esta tecnica un total de 10 pacientes, desde Noviembre de 2006 hasta la fecha. La principal indicacion en nuestro caso ha sido la presencia de prolapsos pelvicos sintomaticos, habiendose intervenido tanto pacientes histerectomizadas como no histerectomizadas, sin poder establecer diferencias significativas entre ambos casos. Como estudio preoperatorio se ha incluido: Cistografia, Ecografia Reno-vesical, Estudio Urodinamico en todos los casos, y tan solo en aquellos en los que se ha considerado oportuno una Uro-Resonancia. Todas las pacientes han sido intervenidas bajo anestesia general, mediante colocacion de un minimo de tres trocares roboticos (8mm) y uno convencional para el ayudante, aunque en algunos casos, sobretodo al inicio de la serie se precisaron 2 trocares accesorios. Asi mismo, en nuestra serie en la mayoria de los casos se ha asociado una tecnica anti-incontinencia tipo sling suburetral transobturatriz, bien para tratamiento de la incontinencia urinaria de esfuerzo (IUE), bien para prevenir su posible aparicion tras la correcion del prolapso. Los resultados obtenidos son comparables a los descritos en otras series mas numerosas en cuanto a duracion, estancia hospitalaria y complicaciones tanto precoces como tardias. A expensas de realizar una valoracion a largo plazo y con series mas amplias, podemos incluir la colposacropexia laparoscopica asistida por robot entre el arsenal terapeutico disenado para la reparacion de los prolapsos del suelo pelvico sintomaticos.

Key Areas in the Learning Curve for Robotic Urological Surgery: A Spanish Multicentre Survey

Background: The number of robotic-assisted procedures offered in Spain is rapidly increasing despite a lack of consensus criteria for training and credentialling. Objective: This national multicentre study was designed to analyze the different areas of the robotic urological surgery learning curve. Material and Methods: A questionnaire was sent to all 13 urology units in Spain with an active robotics programme requesting information on training and problems encountered. Results: In most centres (n = 11, 84.6%), training programmes were animal-based; cadavers were used at only 2 (15.4%). Proctoring in initial procedures was practiced by 12 groups (92.3%). When initiating the robotics programme, the console was shared at 8 units (61.5%). Prior experience in open and/or laparoscopic surgery was reported by 10 of the groups (76.9%), and experience in open surgery only by 2 (15.4%) or robotic surgery alone by 1 (7.7%). The procedure with which the robotics programme was started in all 13 participating units was radical prostatectomy. The number of cases needed to complete the learning curve for this procedure was 20–25 cases according to 8 (61.5%) surgery teams. Conclusions: Up until March 26, 2010, 1,692 operations, mostly radical prostatectomies, were conducted using the da Vinci robot in our country.BACKGROUND The number of robotic-assisted procedures offered in Spain is rapidly increasing despite a lack of consensus criteria for training and credentialling. OBJECTIVE This national multicentre study was designed to analyze the different areas of the robotic urological surgery learning curve. MATERIAL AND METHODS A questionnaire was sent to all 13 urology units in Spain with an active robotics programme requesting information on training and problems encountered. RESULTS In most centres (n = 11, 84.6%), training programmes were animal-based; cadavers were used at only 2 (15.4%). Proctoring in initial procedures was practiced by 12 groups (92.3%). When initiating the robotics programme, the console was shared at 8 units (61.5%). Prior experience in open and/or laparoscopic surgery was reported by 10 of the groups (76.9%), and experience in open surgery only by 2 (15.4%) or robotic surgery alone by 1 (7.7%). The procedure with which the robotics programme was started in all 13 participating units was radical prostatectomy. The number of cases needed to complete the learning curve for this procedure was 20-25 cases according to 8 (61.5%) surgery teams. CONCLUSIONS Up until March 26, 2010, 1,692 operations, mostly radical prostatectomies, were conducted using the da Vinci robot in our country.

Current state of digestive system robotic surgery in the light of evidence based medicine

Abstract The incorporation of robotics in minimally invasive surgery has had mixed reception in the different fields of digestive surgery. Nowadays we are exposed to a continuous stream of publications on robotic approach techniques and outcomes, which do not always provide objective criteria and whose value, through scientific evidence analysis, is sometimes arguable. With the aim of shedding light on current knowledge on digestive robotic surgery and giving an update of its possibilities, the authors analyse the abundant literature available on the different digestive robotic surgery procedures, and sum up their own experience.

Multidisciplinary development of robotic surgery in a University Tertiary Hospital: Organization and outcomes

Background: Da Vinci system (Intuitive Surgical ® ) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation…) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in

Desarrollo multidisciplinario de la cirugía robótica en un hospital universitario de tercer nivel: organización y resultados

Background Da Vinci system (Intuitive Surgical®) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation…) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006. We present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC.BACKGROUND Da Vinci system (Intuitive Surgical) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation...) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006. We present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC. MATERIAL AND METHODS Starting from joint management and joint scrub nurses team, General and Digestive Surgery, Urology and Gynaecology Departments were progressively incorporated into the Robotic Surgery Plan, with several procedures increasing in complexity. A number of intra and extra-hospital teaching and information activities were planned to report on the Robotic Surgery Plan. RESULTS Between July 2006 and July 2008, 306 patients were operated on: 169 by General Surgery, 107 by Urology and 30 by Gynaecology teams. The outcomes showed feasibility and a short learning curve. The educational plan included residents and staff interested in robotic technology application. CONCLUSION The structured and gradual incorporation of robotic surgery throughout the PCR-HCSC has made it easier to learn, to share designed infrastructure, to coordinate information activities and multidisciplinary collaboration. This preliminary experience has shown the efficiency of an adequate organization and motivated team.

Key Areas in the Endourology, Laparoscopic and Robotic Urologic Surgery Learning: A Resident Spanish Multicentre Survey

Objective: To determine the current state of training of urology residents in Spain in laparoscopic surgery and robotic urologic surgery Methods: At the Department of Urology of the Clinico San Carlos Hospital in Madrid these methods were surveyed and directed to Spanish residents, during the period between 2011 and May 2012. We designed a survey that was disseminated through the website (www.seclaendosurgery.com) of the Spanish Society of Laparoscopic and Robotic Surgery (SECLA) to all intern doctors at any Spanish hospital Results: Of a total of 384 residents in Urology, 36 responded to the survey (9.3%). The data related to endoscopic procedures showed that 25% of respondents have never participated in the placement of a percutaneous nephrostomy (n=36), or expected to. By contrast, 77% say that they have done it as surgeons in ureteroscopy (n=36) and 25% did it in more than ten procedures. The 54’4% of respondents have participated as surgeons in percutaneous nephrolitectomy (n=28) and 79% expected to do it. The participation of residents in assisted procedures with the da Vinci robot is low. Laparoscopic procedures are of great interest and participation is reduced on increasing the complexity of the procedure. 41.6% of respondents think that their training is adequate while 58.3% think it is not. 88% think that their training could be improved with courses and seminars and by gaining more responsibility in the operating room and 50% that their training could be supplemented with external rotations and/or fellowships Conclusion: It is necessary to define what the best ways are to start in laparoscopy surgery and to improve participation in basic laparoscopic procedures to improve the residents’ skills and to get the right training in more difficult surgeries. The participation in endoscopic procedures is acceptable.

Robotic-Assisted Laparoscopic Sacrocolpopexy: Temporary Phenomenon or a New Consolidated Technique

ration of normal anatomy, retain the axis and depth of the vagina thus preserving sexual function, and provide a lasting result in time. Unfortunately, these are difficult goals to achieve with one specific technique. The first comparison series between ACSP and LCSP was published by Parai so et al. [6] who described the advantages and disadvantages. The advantages of the LCSP include a shorter hospital stay, less postoperative pain and less bleeding. The disadvantages are a longer learning curve and increased operative time. In selected cases, the disadvantages become an investment to obtain good results by minimally invasive surgery. We were struck by the meta-analysis of 1,000 patients published by Gamatra et al. [7] in European Urology in 2009. It describes quite comparable results between ACSP and LCSP, suggesting the need for minimally invasive techniques to undermine the ACSP. The continuous development and advances in medicine and the application of new technologies have allowed the introduction of robotics as a tool for surgeons. In this sense, the first robotic urological procedure approved by the FDA was radical prostatectomy, and robotic colposacropexy was approved in April 2005. Robotic colposacropexy was used for the first time The best approach to the restoration of the vagina remains controversial. Historically, vaginal and abdominal approaches have been used in the treatment of pelvic organ prolapse (POP). The vaginal vault support above the sacrum, using synthetic material is a durable technique and preserves the axis and depth of the vagina. This allows patients to maintain normal sexual activity [1–5] . What still seems uncertain is whether this method will be comparable to other minimally invasive transvaginal approaches, but the absence of published studies causes a lack in the knowledge. Supporting the existing literature [2– 5] , we highlight the following considerations so they can be applied in clinical practice: (1) In vaginal vault prolapse, the abdominal colposacropexy (ACSP) provides a lower rate of recurrence and dyspareunia compared with sacrospinous colpopexy. (2) In apical prolapse, ACSP has a success rate ranging from 78 to 100%. This makes it a ‘gold standard’ technique. (3) Laparoscopic colposacropexy (LCSP) provides a shorter convalescence and less morbidity than ACSP, but at the expense of a longer learning curve. Before proceeding, we must consider what goals we want to achieve with surgery for pelvic organ prolapse. In this sense, we believe that surgery should improve the symptoms of prolapse, appropriate restoReceived: August 25, 2011 Accepted: September 13, 2011 Published online: January 11, 2012ration of normal anatomy, retain the axis and depth of the vagina thus preserving sexual function, and provide a lasting result in time. Unfortunately, these are difficult goals to achieve with one specific technique. The first comparison series between ACSP and LCSP was published by Paraiso et al. [6] who described the advantages and disadvantages. The advantages of the LCSP include a shorter hospital stay, less postoperative pain and less bleeding. The disadvantages are a longer learning curve and increased operative time. In selected cases, the disadvantages become an investment to obtain good results by minimally invasive surgery. We were struck by the meta-analysis of 1,000 patients published by Gamatra et al. [7] in European Urology in 2009. It describes quite comparable results between ACSP and LCSP, suggesting the need for minimally invasive techniques to undermine the ACSP. The continuous development and advances in medicine and the application of new technologies have allowed the introduction of robotics as a tool for surgeons. In this sense, the first robotic urological procedure approved by the FDA was radical prostatectomy, and robotic colposacropexy was approved in April 2005. Robotic colposacropexy was used for the first time The best approach to the restoration of the vagina remains controversial. Historically, vaginal and abdominal approaches have been used in the treatment of pelvic organ prolapse (POP). The vaginal vault support above the sacrum, using synthetic material is a durable technique and preserves the axis and depth of the vagina. This allows patients to maintain normal sexual activity [1–5] . What still seems uncertain is whether this method will be comparable to other minimally invasive transvaginal approaches, but the absence of published studies causes a lack in the knowledge. Supporting the existing literature [2– 5] , we highlight the following considerations so they can be applied in clinical practice: (1) In vaginal vault prolapse, the abdominal colposacropexy (ACSP) provides a lower rate of recurrence and dyspareunia compared with sacrospinous colpopexy. (2) In apical prolapse, ACSP has a success rate ranging from 78 to 100%. This makes it a ‘gold standard’ technique. (3) Laparoscopic colposacropexy (LCSP) provides a shorter convalescence and less morbidity than ACSP, but at the expense of a longer learning curve. Before proceeding, we must consider what goals we want to achieve with surgery for pelvic organ prolapse. In this sense, we believe that surgery should improve the symptoms of prolapse, appropriate restoReceived: August 25, 2011 Accepted: September 13, 2011 Published online: January 11, 2012

OriginalDesarrollo multidisciplinario de la cirugía robótica en un hospital universitario de tercer nivel: organización y resultadosMultidisciplinary development of robotic surgery in a University Tertiary Hospital: Organization and outcomes

Background Da Vinci system (Intuitive Surgical®) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation…) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006. We present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC.BACKGROUND Da Vinci system (Intuitive Surgical) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation...) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006. We present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC. MATERIAL AND METHODS Starting from joint management and joint scrub nurses team, General and Digestive Surgery, Urology and Gynaecology Departments were progressively incorporated into the Robotic Surgery Plan, with several procedures increasing in complexity. A number of intra and extra-hospital teaching and information activities were planned to report on the Robotic Surgery Plan. RESULTS Between July 2006 and July 2008, 306 patients were operated on: 169 by General Surgery, 107 by Urology and 30 by Gynaecology teams. The outcomes showed feasibility and a short learning curve. The educational plan included residents and staff interested in robotic technology application. CONCLUSION The structured and gradual incorporation of robotic surgery throughout the PCR-HCSC has made it easier to learn, to share designed infrastructure, to coordinate information activities and multidisciplinary collaboration. This preliminary experience has shown the efficiency of an adequate organization and motivated team.