Gabriel Ogaya-Pinies

Safety of Live Robotic Surgery: Results from a Single Institution

BACKGROUND Live surgery events (LSEs) have become one of the most attended activities at surgical meetings and provide a unique opportunity for the audience to observe the decision-making process used by skilled and experienced surgeons in real time. However, there is an ongoing discussion on whether patients treated during LSE are at higher risk of complications. OBJECTIVE To examine LSE outcomes for robot-assisted radical prostatectomy (RARP) and establish patient safety and efficacy. DESIGN, SETTING, AND PARTICIPANTS From January 2008 to April 2016, >9000 patients underwent RARP at our institution, performed by a single surgeon. From this group, 36 patients underwent live RARP surgery (LS group) transmitted via video link from our institution to an external congress. A control group was obtained from our database to compare outcomes between the LS group and patients undergoing RARP under regular circumstances. The data were prospectively collected in a customized database and retrospectively analyzed. INTERVENTION All patients underwent RARP performed by a single surgeon at our institution. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Postoperative outcomes were compared between the LS (n=36) and the control (n=108) groups using Students t test and analysis of variance for continuous variables, and a two-tailed Fishers exact test for categorical variables. Statistical significance was set at p<0.05. RESULTS AND LIMITATIONS There were no significant differences in baseline characteristics (age, body mass index, comorbidities, preoperative Gleason score, Sexual Health Inventory for Men score and American Urological Association symptom score) between the groups. The median console time was shorter for the LS group (73min, interquartile range [IQR] 70-79) than for the control group (78min, IQR 75-87; p=0.0371). No major complications were reported in either group, and only four minor complications were observed in the control group (p=0.2415). After median follow-up of 31 mo (IQR 18-50), only one patient (2.77%) in the LS group experienced biochemical recurrence, compared to four (3.71%) in the control group (p=0.7927). There was no significant difference in continence rates between the LS and control groups (97.22% vs 93.52%; p=0.7768). No differences in potency rate were evident by the end of the follow-up period (LS 69.44%, control group 70.37%; p=0.8432). The retrospective nature, the lack of randomization, and the single-institution experience are limitations of the study. CONCLUSIONS In this series of live transmitted RARPs, perioperative results (oncological and functional outcomes and complications) were similar to those found in daily practice. After careful patient selection, LSEs are safe with minimal patient morbidity in the hands of an experienced surgeon working with a familiar surgical team. Further evaluation of the results from other surgeons at other centers is necessary. PATIENT SUMMARY We investigated the safety of surgeries broadcast live from our institution. We found that outcomes were similar to those for patients undergoing surgery under regular circumstances in terms of the rate of complications and oncological and functional outcomes. We conclude that live transmitted surgery is safe in well-selected patients in the hands of an experienced surgeon.

Technical Modifications for Salvage and Complex Radical Prostatectomy

Robotic radical prostatectomy is a procedure that has evolved considerably in the last 15 years as one of the main treatments for localized prostate cancer. Published literature currently describes in detail the procedure and outcomes. However, as widespread as it may be, we believe that certain technical modifications have greatly improved our technique, hence improving early and medium-term outcomes. After having performed close to 10,000 cases (single surgeon series—VP), our technique has evolved significantly, including several refinements to reduce patient morbidity and further improve the functional outcomes. In the present manuscript, we perform a detailed description of our surgical technique of Robotic-Assisted Laparoscopic Radical Prostatectomy and provide practical recommendations based on available reports and personal experience.

Nerve-sparing in salvage robot-assisted prostatectomy: surgical technique, oncological and functional outcomes at a single high-volume institution

To show the feasibility, oncological and functional outcomes of neurovascular bundle (NVB) preservation during salvage robot‐assisted radical prostatectomy (RARP).

MP93-12 PROSTATE CANCER IN MEN YOUNGER THAN 55: RATES OF FUNCTIONAL RECOVERY POST-ROBOTIC ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY

return of urinary continence, and recovery of sexual function that constitute the RARP 00trifecta00. A method to quantifying RARP outcome was developed in Europe that classifies survival (S), continence (C), and potency (P). The SCP mimics the TNM system used for staging. We sought to validate SCP in a large cohort of Americans followed for more than 5 years after RARP. METHODS: A retrospective review of prospectively collected data from 800 men who underwent RARP from Jan 2006 to Dec 2011 was performed. Total of 637 men were used for analysis after applying inclusion and exclusion criteria. NCCN biochemical failure was used as a proxy for oncologic outcome (S). The UCLA-Prostate Cancer Index Urinary Function and Sexual Function Questionnaires were used to evaluate continence (C) and potency (P), respectively. Continence was refined further by querying medical records for use of a security pad. RESULTS: The 5and 10-year biochemical progression-free survival rates were 93% (95% CI: 0.90-0.95) and 73% (95% CI: 0.67-0.79), respectively. At last follow up, 502 (79%) patients used no pads (C0), 70 (11%) patients used one security pad (C1), 63 (9.8%) patients used one or more pads routinely (C2), and 2 (0.2%) patients were incontinent before RARP (Cx). Of the 522 (82%) patients who had bilateral nerve-sparing RARP, 128 (24.5%) patients were fully potent without use of aids (P0), 74 (14.2%) patients were potent with PDE-5 inhibitor (P1), 320 (61.3%) patients experienced erectile dysfunction (P2). 115 (18%) patients were impotent preoperatively or did not undergo bilateral nerve sparing (Px). In patients preoperatively continent and potent who underwent bilateral nerve preservation and did not require adjuvant radiation therapy, oncologic and functional perfection (S0C0P0) was achieved in 58 (45%) patients. Oncologic and continence perfection (S0C0) was achieved in 92 (80%) of patients for whom potency was not recoverable (Px). CONCLUSIONS: SCP classification offers a tool for objective assessment of oncologic and functional outcome after RARP.

V8-09 ROBOT ASSISTED RADICAL PROSTATECTOMY FOR PROSTATES OVER 100 GRAMS: TECHNIQUE AND OUTCOMES

previously reported Milan vas deferens sling technique by adding reinforcement of under-anastomosis layers during robot-assisted radical prostatectomy, which significantly accelerates early recovery of postoperative urinary continence in cases without nerve-sparing. METHODS: Modified sling technique; Sling suture was made from autologous vas deferens. After putting the vas deferens sling on the sub-urethral perirectal fat, three independent layers were constructed below the urethrovesical anastomosis, and a single anterior layer was made. Then, both ends of the sling were transfixed to Cooper ligaments bilaterally with adequate sling suspension. Between October 2015 and July 2016, consecutive 35 patients who underwent robotassisted radical prostatectomy without nerve-sparing at our institution with a single surgeon were investigated. The patients were classified into two groups: 15 using the sling technique (sling group) and 20 using the non-sling technique with simple posterior reconstruction (nonsling group). Urinary continence defined as 0 or safety 1 pad use daily was compared between the groups. RESULTS: Patients’ characteristics were comparable between the groups. Urinary continence rate significantly improved in the sling group (60.0%, p1⁄40.0365) as compared to the nonsling group (25.0%) at 1 month despite no difference at 3 months (86.7% in the sling group vs. 65.0% in the nonsling group, p1⁄40.1467) postoperatively. Postoperative complications related to sling procedure were not detected. CONCLUSIONS: Despite a small sample size in the singleinstitution study, this sling technique may improve early urinary continence recovery after robot-assisted radical prostatectomy even without nerve-sparing. A larger study is needed to confirm its efficacy.

MP93-06 TECHNICAL FACTORS PREVENTING FULL NERVE SPARING DURING ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY IN PATIENTS THAT ARE CANDIDATES FOR FULL NERVE SPARING

RESULTS: The recovery of incontinence was similar to the two groups at 6 and 12 months after the surgery. However, patients underwent RARP restored the continence sooner than those in the LRP group in 1 and 3 months after the surgery (P <0.001 and 0.001) (Fig.1). For the multivariable analysis, the type of RP procedure was a uniquely meaningful contributing factor (P 1⁄4 0.001, HR 1⁄4 1.925; 95% CI 1⁄4 1.299e2.851). In the case of urinary function, the RARP groups showed a better IPSS score than LRP groups at the 1-, 3-, and 6-month visits, respectively (P 1⁄4 0.008, 0.026, 0.001), (Fig.2) and the RARP groups early improved compared with LRP groups at the 3-month visit in the case of erectile function (P 1⁄4 0.018) (Fig.3). CONCLUSIONS: The RARP tended toward getting back the urinary continence earlier than the LRP. In addition, urinary and erectile function recovered more quickly in the RARP group than in the LRP group.

Surgical Robotics: Past, Present and Future

The evolution of robots in surgical practice is an intriguing story that spans cultures, continents and centuries. The idea of reproducing himself with the use of a mechanical robot has been in man’s imagination in the last 3000 years. However, the use of robots in medicine has only 30 years of history. Surgery has traditionally required larger incisions to allow the surgeon to introduce his hands into the body and to allow sufficient light to see the structures being operated on. Surgeon directly touched and felt the tissues and moved the tip of the instruments. However, innovations have radically changed the performance of surgical procedures in operating room by digitization, miniaturization, improved optics, novel imaging techniques, and computerized information systems. These surgical procedures can be done by manipulating instruments from outside the patient, by looking at displays of direct electronic images of the target organs on the monitor. The robot completes the transition to the Information Age. The surgeon is immersed in this computer-generated environment (called “virtual reality,” term coined by Jaron Lanier, 1986) and sends electronic signals from the joysticks of the console to the tip of the instruments, which mimic the surgeon’s hand movements [1].

Robotic Assisted Radical Prostatectomy

Radical prostatectomy is one of the gold standard treatments for clinically localized prostate cancer. Since introduced in 2001 robotic assistance has significantly changed the surgical management of clinically localized prostate cancer. Within a decade, robot assisted laparoscopic radical prostatectomy (RALP) is being utilized worldwide. In the USA, more than 80 % of radical prostatectomies are performed with robot assistance [1]. Several technical modifications evolved with the principle of achieving trifecta. Our group introduced the concept of pentafecta with key components of local tumor control with negative surgical margins, less perioperative morbidity while preserving continence and sexual function [2].

Robotic Laparoscopic Pyeloplasty

Minimal access reconstructive surgery has evolved in a large way over past two decades. Laparoscopic pyeloplasty (LP) was first introduced in 1993 by Schuessler et al. [1]. Since then, it has rapidly become part of the urologic armamentarium for the treatment of primary ureteropelvic junction obstruction (UPJO) [2].

Complications in robotic urological surgeries and how to avoid them: A systematic review

Abstract Objectives: To review the main complications related to the robot-assisted laparoscopic (RAL) approach in urology and to suggest measures to avoid such issues. Methods: A systematic search for articles of the contemporary literature was performed in PubMed database for complications in RAL urological procedures focused on positioning, access, and operative technique considerations. Each complication topic is followed by recommendations about how to avoid it. Results: In all, 40 of 253 articles were included in this analysis. Several complications in RAL procedures can be avoided if the surgical team follows some key steps. Adequate patient positioning must avoid skin, peripheral nerve, and muscles injuries, and ocular and cognitive complications mainly related to steep Trendelenburg positioning in pelvic procedures. Port-site access and closure should not be neglected during minimally invasive procedures as these complications although rare can be troublesome. Technique-related complications depend on surgeon experience and the early learning curve should be monitored. Conclusions: Adequate patient selection, surgical positioning, mentorship training, and avoiding long-lasting procedures are essential to prevent RAL-related complications. The robotic surgical team must be careful and work together to avoid possible complications. This review offers several steps in surgical planning to reach this goal.