Gerald J. Wang

Robotic vs open radical cystectomy : prospective comparison of perioperative outcomes and pathological measures of early oncological efficacy

To prospectively compare perioperative and pathological outcomes in a consecutive series of patients undergoing radical cystectomy (RC) and urinary diversion by the open or the robotic approach.

A Comparison of Postoperative Complications in Open versus Robotic Cystectomy

BACKGROUND Robotic cystectomy is an emerging alternative for treatment of invasive bladder cancer (BCa). However, reduction in postoperative morbidity relative to the open approach has not been demonstrated. OBJECTIVE To compare complication rates in patients undergoing robotic versus open radical cystectomy (RC). DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study of 187 consecutive patients undergoing RC at our institution-104 open RC, 83 robotic RC. INTERVENTION Open or robotic RC with urinary diversion. MEASUREMENTS Demographic, perioperative, and complication data were recorded prospectively. Thirty-day and 90-d complication rates were assessed using the modified Clavien complication scale. Data were evaluated using chi(2) and multivariate logistic regression analyses. RESULTS AND LIMITATIONS At 30 d, the open group demonstrated a higher overall complication rate (59% vs 41%; p=0.04) as well as more major complications (30% vs 10%; p=0.007). At 90 d, the overall complication rate was greater in the open group, but this was not statistically significant (62% vs 48%; p=0.07). However, there was a significantly higher major complication rate in the open cohort (31% vs 17%; p=0.03). When subjected to logistic regression analysis, robotic cystectomy was an independent predictor of fewer overall and major complications at 30 and 90 d. High American Society of Anesthesiologists (ASA) score (3-4) and longer surgical time were independent predictors of major complications. Though this is one of the largest published RC series, the sample size is relatively small. Moreover, despite the two patient cohorts being similarly matched, the study was not performed in a randomized fashion. CONCLUSIONS Patients undergoing robotic cystectomy experienced fewer postoperative complications than those undergoing open cystectomy. Robotic cystectomy is an independent predictor of fewer overall and major complications. Until long-term oncologic results are available, robotic cystectomy should still be considered investigational.

Critical analysis of complications after robotic-assisted radical cystectomy with identification of preoperative and operative risk factors

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

Comparison of laparoendoscopic single-site donor nephrectomy and conventional laparoscopic donor nephrectomy: donor and recipient outcomes.

OBJECTIVE To present a comparison of perioperative donor outcomes and recipient graft function in a series of patients undergoing laparoendoscopic single-site donor nephrectomy (LESS-DN) versus conventional laparoscopic donor nephrectomy (LDN). METHODS Data were collected for 50 consecutive LESS-DN patients and a matched cohort of 50 LDN patients. The donor outcomes analyzed included operative time, estimated blood loss, complications, visual analog pain scores, and recovery time. The recipient outcomes analyzed included serum creatinine at discharge and follow-up and the incidence of delayed graft function. RESULTS The mean total operative time was shorter in the LDN group than in the LESS-DN group (P < .0001). Linear regression analysis of the LESS-DN operative times relative to case number showed a significant decrease in the operative time with increasing case number (r(2) = 0.19, P = .002). No statistically significant differences were found in estimated blood loss, warm ischemia time, length of stay, or visual analog pain scores between the 2 groups. However, the surgical incision was significantly smaller in the LESS-DN group (P < .0001). After discharge, the patient-reported time to complete recovery was faster in the LESS-DN group (P = .01). The incidence of complications was similar in both groups; however, major complications only occurred in the LDN group. No differences were found in the recipient serum creatinine values or the incidence of delayed graft function. CONCLUSION Our initial experience with LESS-DN is encouraging. This retrospective matched-pair comparison between LESS-DN and LDN suggests that the single-port approach might be associated with quicker convalescence. Longer operative times in the LESS-DN group could simply represent the learning curve of a novel procedure.

ANTAGONISM OF BMP4 SIGNALING DISRUPTS SMOOTH MUSCLE INVESTMENT OF THE URETER AND URETEROPELVIC JUNCTION

PURPOSE Congenital ureteropelvic junction obstruction has been associated with aberrant ureteral smooth muscle organization. Recent evidence has shown that BMP4 may be involved in ureteral morphogenesis. We determined whether the disruption of BMP4 signaling results in abnormal smooth muscle investment of the ureter and ureteropelvic junction. MATERIALS AND METHODS We used a Cre mediated Bmp4 knockout system to conditionally excise the Bmp4 gene in developing mouse embryos. Kidney rudiments were isolated from embryos at varying gestational ages from WT and conditional knockout mice. Metanephric kidney explants were cultured in the presence or absence of the BMP antagonist Noggin. Agarose beads pre-incubated with Gremlin, another BMP antagonist, were used for localized disruption of BMP signaling. Frozen sections and whole metanephric explants were then analyzed by immunofluorescence. RESULTS Bmp4 gene excision resulted in a dose dependent loss of ureteral smooth muscle. Antagonism of BMP signaling inhibited ureteral smooth muscle investment in a dose dependent manner and was paralleled by a dose dependent decrease in the immediate downstream targets of BMP signaling, phosphorylated Smad1, 5 and 8. Localized antagonism of BMP resulted in the focal disruption of ureteral smooth muscle investment. CONCLUSIONS We report that decreased BMP signaling, whether by the loss of BMP4 in vivo or direct antagonism in vitro, results in a gradual reduction of the normal, well organized coat of smooth muscle surrounding the ureter. Our results also suggest that this occurs via a direct Smad dependent pathway. This raises the possibility that abnormalities in BMP4 signaling may have a role in the development of congenital ureteropelvic junction obstruction.

Robot-Assisted Radical and Partial Cystectomy

Indications for robot-assisted radical cystectomy are identical to those of the open approach and the goal is surgical cure of disease. However, level of difficulty must be balanced with surgeon comfort and experience, and one must always be prepared for open conversion. A growing body of literature suggests partial cystectomy may represent a viable alternative; however, appropriate patient selection is of paramount importance. Traditional indications include a solitary tumor in a favorable location and absence of carcinoma in situ. We review our stepwise approach to surgical management of invasive bladder cancer.

Robot-Assisted Radical Cystoprostatectomy

Open radical cystectomy remains the gold standard for treatment of muscle-invasive bladder cancer. However, efforts to reduce the operative morbidity of open radical cystectomy have fostered interest in minimally invasive approaches. Both laparoscopic and robot-assisted laparoscopic approaches have been reported (Turk I, DeGer S, Winkelman B, Schoberger B, Loening SA, J Urol 165:1863–1866, 2001; Gill IS, Kaouk JH, Meraney AM et al., J Urol 168:13–18, 2002; Xavier C, Arroyo C, Rozet F, Barret E, Vallancien G, Eur Urol 47:780–784, 2005; Menon M, Hemal AK, Tewari A, et al., BJU Int 92:232–236, 2003; Hemal AK, Abdol-Enein H, Tewari A et al., Urol Clin N Am 31:719–729, 2004; Pruthi RS, Wallen EM, J Urol 178:814–818, 2007; Wang GJ, Barocas DA, Raman JD, Scherr DS, BJU Int 101:89–93, 2007). Advantages of minimally invasive approaches are well documented, including decreased blood loss, less postoperative pain, faster recovery and return of bowel function, and shorter hospital stay (Xavier C, Arroyo C, Rozet F, Barret E, Vallancien G, Eur Urol 47:780–784, 2005; Hemal AK, Abdol-Enein H, Tewari A et al., Urol Clin N Am 31:719–729, 2004; Pruthi RS, Wallen EM, J Urol 178:814–818, 2007; Wang GJ, Barocas DA, Raman JD, Scherr DS, BJU Int 101:89–93, 2007). However, long-term oncologic and functional outcomes are yet to be reported. Nevertheless, we and others have reported on pathologic outcomes of early oncologic significance such as surgical margin status and number of lymph nodes removed during pelvic lymphadenectomy (Pruthi RS, Wallen EM, J Urol 178:814–818, 2007; Wang GJ, Barocas DA, Raman JD, Scherr DS, BJU Int 101:89–93, 2007). Our findings suggest that the robotic approach can yield pathologic measures of early oncologic efficacy equivalent to that of open radical cystectomy (Wang GJ, Barocas DA, Raman JD, Scherr DS, BJU Int 101:89–93, 2007). We also show that the robotic approach allows for a lymph node dissection up to and beyond the level of the common iliac artery, and that the total number of lymph nodes removed is not diminished compared to the open technique (Wang GJ, Barocas DA, Raman JD, Scherr DS, BJU Int 101:89–93, 2007). Nevertheless, larger, randomized studies with long-term functional and oncologic outcomes are required to better define the role and oncologic safety of robot-assisted radical cystectomy in the surgical management of bladder cancer. Herein, we describe our technique of robot-assisted laparoscopic radical cystectomy. A governing theme in our technique is a strict adherence to the oncologic principles underlying open radical cystectomy. We have divided our technique into 16 steps and include a complete description of our operating room setup, patient positioning, trocar placement, and instrument list. We provide specific details of our step-by-step procedure, including our process of redocking the robot after extracorporeal orthotopic neobladder creation for the urethral-neobladder anastomosis. Each step is illustrated with an intraoperative photo and an accompanying line drawing. Extracorporeal urinary diversion in our series includes ileal conduit, continent cutaneous diversion, and orthotopic ileal neobladder (W-pouch with afferent limb). Our technique of urinary diversion has been described elsewhere (Rowland RG, Mitchell ME, Bihrle R, Kahnoski RJ, Piser JE, J Urol 137:1136–1139, 1987; Hautmann RE, Egghart G, Frohneberg D, Miller K, J Urol 139:39–42, 1988) and is beyond the scope of this chapter. We conclude with a list of special considerations for robotic cystectomy in female patients.

Comparison of laparoendoscopic single-site donor nephrectomy and conventional laparoscopic donor nephrectomy: donor and recipient outcomes

OBJECTIVE To present a comparison of perioperative donor outcomes and recipient graft function in a series of patients undergoing laparoendoscopic single-site donor nephrectomy (LESS-DN) versus conventional laparoscopic donor nephrectomy (LDN). METHODS Data were collected for 50 consecutive LESS-DN patients and a matched cohort of 50 LDN patients. The donor outcomes analyzed included operative time, estimated blood loss, complications, visual analog pain scores, and recovery time. The recipient outcomes analyzed included serum creatinine at discharge and follow-up and the incidence of delayed graft function. RESULTS The mean total operative time was shorter in the LDN group than in the LESS-DN group (P .0001). Linear regression analysis of the LESS-DN operative times relative to case number showed a significant decrease in the operative time with increasing case number (r 2 0.19, P .002). No statistically significant differences were found in estimated blood loss, warm ischemia time, length of stay, or visual analog pain scores between the 2 groups. However, the surgical incision was significantly smaller in the LESS-DN group (P .0001). After discharge, the patient-reported time to complete recovery was faster in the LESS-DN group (P .01). The incidence of complications was similar in both groups; however, major complications only occurred in the LDN group. No differences were found in the recipient serum creatinine values or the incidence of delayed graft function. CONCLUSION Our initial experience with LESS-DN is encouraging. This retrospective matched-pair comparison between LESS-DN and LDN suggests that the single-port approach might be associated with quicker convalescence. Longer operative times in the LESS-DN group could simply represent the learning curve of a novel procedure. UROLOGY 78: 1332‐1337, 2011.