J. Slade Hubbard

Robot-Assisted Laparoscopic Anterior Pelvic Exenteration for Bladder Cancer in the Female Patient

INTRODUCTION Recent small case series have now been reported for robotic-assisted laparoscopic radical cystectomy. Herein, we describe our approach and initial experience with robotic-assisted laparoscopic anterior pelvic exenteration in the female patient with bladder cancer. METHODS We describe the technique of robotic-assisted laparoscopic anterior pelvic exenteration. The classic da Vinci or the da Vinci S robotic platform is utilized for the procedure. In our experience, 12 women underwent robotic-assisted laparoscopic anterior pelvic exenteration and extracorporeal urinary diversion for clinically localized bladder cancer. RESULTS Mean age was 67.9 years (range 61-79 years). Nine patients underwent ileal conduit diversion and three patients underwent an orthotopic neobladder. In all cases, the urinary diversion was performed extracorporeally. Mean operating room time was 4.6 h; mean surgical blood loss was 221 mL. On surgical pathology, seven patients were =pT2, three patients were pT3, and two patients were N+. In no case was there positive surgical margins, and in one case there was inadvertent entry into the bladder. Mean number of lymph nodes removed was 19 (range 12-34). Mean time to flatus was 1.9 days and to bowel movement 2.4 days, and time to discharge 4.8 days. Six patients were discharged on postoperative day 4, four patients on postoperative day 5, one on postoperative day 6, and one on postoperative day 8. There were two postoperative complications (17%) in two patients. CONCLUSIONS Our initial experience with robotic-assisted laparoscopic anterior pelvic exenteration appears to be favorable with acceptable operative, pathologic, and short-term clinical outcomes. Certainly, larger experiences are required to adequately evaluate and validate this procedure as an appropriate surgical and oncologic option.

Incisional Hernia in a 12-mm Non-Bladed Trocar Site following Laparoscopic Nephrectomy

Non-bladed trocars, radially-dilating systems, and conical blunt devices are considered less traumatic to the abdominal wall because they do not incise the fascia itself. Consequently, several authors have suggested that closure of the abdominal fascia may be unnecessary if such non-bladed laparoscopic trocars are used. We report of a case in whom a port-site hernia was diagnosed at the site of a 12-mm non-bladed trocar 11 days after laparoscopic nephrectomy.

Robotic Anterior Pelvic Exenteration for Bladder Cancer in the Female: Outcomes and Comparisons to Their Male Counterparts

BACKGROUND Recent small case series have now been reported for robotic-assisted laparoscopic radical cystectomy. The majority of these series have reported techniques and outcomes in a predominantly male patient population. The application of such novel techniques to female cystectomy and anterior exenterative procedures has not been well documented and described. In this paper, we report our initial experience with robotic anterior pelvic exenteration in the female with bladder cancer evaluating perioperative and pathologic outcomes of this novel procedure and comparing the outcomes to those observed in their male counterparts. METHODS Fifty patients underwent a robotic radical cystectomy and extracorporeal diversion for clinically localized bladder cancer: 40 male patients (robotic radical cystoprostatetctomy) and 10 women (robotic anterior pelvic exenteration). Outcome measures evaluated in this series included operative variables, hospital recovery, pathologic outcomes, and complication rate. RESULTS Mean age of female patients was 68.4 years and of male patients was 62.8. Mean operating room time was 4.6 hours, and mean surgical blood loss was 215 mL. On surgical pathology, 5 patients were <=pT2, 3 patients pT3, and 2 patients N+. In no case was there a positive surgical margin, though in 1 case there was inadvertent entry into the bladder. Mean number of lymph nodes removed was 19 (range, 12-34). Mean time to flatus was 1.9 days, time to bowel movement 2.4 days, and time to discharge 4.9 days. These outcomes were comparable to the male patients, particularly the 20 male patients undergoing robotic radical cystoprostatectomy during the same time period. CONCLUSIONS In our experience, the robotic anterior exenteration has been readily adapted to the surgical treatment of bladder cancer with similar outcomes to those observed in male patients undergoing a robotic radical cystoprostatectomy. The approach appears to achieve the clinical and oncologic goals of radical cystectomy in both the female and male patient.

Androgen-independent prostate cancer treated with resection of the solitary metastatic site.

The concept of resection of a solitary metastatic lesion is quite foreign in prostate cancer, as metastases to regional lymph nodes or to other distant sites are most likely suggestive of disseminated disease. The current report demonstrates a very unique case, in whom excision of a solitary pulmonary metastasis has resulted in continued undetectable prostate-specific antigen values over 3 years after resection. Nevertheless, the presence of unusual cases such as this, as well as the work of others, may suggest that surgical excision of solitary or oligometastatic sites could at least be considered for the most highly selected and well-informed patients, whose clinical scenario indicates a potential benefit from such an approach.

A prospective evaluation of the short‐term impact and recovery of health‐related quality of life in men undergoing radical prostatectomy

To prospectively evaluate the acute and short‐term effects of radical retropubic prostatectomy (RRP) on health‐related quality of life (HRQoL) using a validated generic HRQoL instrument that measures overall health status, as although there is increasing interest in the HRQoL of patients being treated for prostate cancer, most studies have focused on long‐term outcomes.

Incisional Hernia in a 12-mm Nonbladed Trocar Site Following Laparoscopic Nephrectomy

Non-bladed trocars and radially dilating systems are considered less traumatic to the abdominal wall because they do not incise the fascia itself. Since the fascia is not cut, it has believed that the fascia closes by itself. Consequently, several authors have suggested that closure of the abdominal fascia may be unnecessary when such non-bladed laparoscopic trocars are used. We report of a case in which a port site hernia was diagnosed at the site of a 12 mm non-bladed trocar 11 days after laparoscopic nephrectomy. Although it may be true that in many cases port site closure is unnecessary and does not result in bowel herniation, this case along with a prior report serve as important reminders that port site hernias are possible even in the use of non-bladed or radial dilating systems, and that there exists a number of potential variables that may predispose to herniation and consequently the ability to predict such events in individual patients remains uncertain. As such, we recommend closing 10 mm or larger port sites irrespective of trocar design.