Jean-Alexandre Long

Comparative Outcomes and Assessment of Trifecta in 500 Robotic and Laparoscopic Partial Nephrectomy Cases: A Single Surgeon Experience

PURPOSE We report a comparative analysis of a large series of laparoscopic and robotic partial nephrectomies performed by a high volume single surgeon at a tertiary care institution. MATERIALS AND METHODS We retrospectively reviewed the medical charts of 500 patients treated with minimally invasive partial nephrectomy by a single surgeon between March 2002 and February 2012. Demographic and perioperative data were collected and statistically analyzed. R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in mm, anterior/posterior and location relative to polar lines) nephrometry score was used to score tumors. Those scored as moderate and high complexity were designated as complex. Trifecta was defined as a combination of warm ischemia time less than 25 minutes, negative surgical margins and no perioperative complications. RESULTS Two groups were identified, including 261 patients with robotic and 231 with laparoscopic partial nephrectomy. Demographics were similar in the groups. The robotic group was significantly more morbid (Charlson comorbidity index 3.75 vs 1.26), included more complex tumors (R.E.N.A.L. score 5.98 vs 7.2), and had lower operative (169.9 vs 191.7 minutes) and warm ischemia (17.9 vs 25.2 minutes) time, intraoperative (2.6% vs 5.6%, each p <0.001) and postoperative (24.53% vs 32.03%, p = 0.004) complications, and positive margin rate (2.9% vs 5.6%, p <0.001). Thus, a higher overall trifecta rate was observed for robotic partial nephrectomy (58.7% vs 31.6%, p <0.001). The laparoscopic group had longer followup (3.43 vs 1.51 years, p <0.001) and no significant difference in postoperative changes in renal function. Main study limitations were the retrospective nature, arbitrary definition of trifecta and shorter followup in the RPN group. CONCLUSIONS Our large comparative analysis shows that robotic partial nephrectomy offers a wider range of indications, better operative outcomes and lower perioperative morbidity than laparoscopic partial nephrectomy. Overall, the quest for trifecta seems to be better accomplished by robotic partial nephrectomy, which is likely to become the new standard for minimally invasive partial nephrectomy.

Robotic Versus Laparoscopic Partial Nephrectomy for Complex Tumors: Comparison of Perioperative Outcomes

BACKGROUND Recent studies showed that robotic partial nephrectomy (RPN) offered outcomes at least comparable to those of laparoscopic partial nephrectomy (LPN). LPN can be particularly challenging for more complex tumors. OBJECTIVE To compare the perioperative outcomes of patients undergoing LPN or RPN for a single renal mass of moderate or high complexity. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis was performed for 381 consecutive patients who underwent either LPN (n = 182) or RPN (n = 199) between 2005 and 2011 for a complex renal mass (RENAL score ≥ 7). Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis. INTERVENTION LPN or RPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis. RESULTS AND LIMITATIONS There was no significant difference between the two groups with respect to patient age, gender, side, American Society of Anesthesiologists score, Charlson comorbidity index (CCI), or tumor size. Patients undergoing LPN had a slightly lower body mass index (29.2 kg/m(2) compared with 30.7 kg/m(2), p = 0.02) and preoperative estimated glomerular filtration rate (eGFR) (81.1 compared with 86.0 ml/min per 1.73 m(2), p = 0.02). LPN was associated with an increased rate of conversion to radical nephrectomy (RN) (11.5% compared with 1%, p<0.001) and a higher decrease in percentage of eGFR (-16.0% compared with -12.6%, p = 0.03). There were no significant differences with respect to warm ischemia time (WIT), estimated blood loss, transfusion rate, or postoperative complications. WIT, preoperative eGFR, and CCI were found to be predictors of postoperative eGFR in multivariable analysis. No difference in perioperative outcomes was found between moderate and high RENAL score subgroups. The retrospective study design was the main limitation of this study. CONCLUSIONS RPN provides functional outcomes comparable to those of LPN for moderate- to high-complexity tumors, but with a significantly lower risk of conversion to RN. This situation is likely because of the technical advantages offered by the articulated robotic instruments. A prospective randomized study is needed to confirm these findings.

Automatic Detection of Instruments in Laparoscopic Images: A First Step Towards High-level Command of Robotic Endoscopic Holders

The tracking of surgical instruments o fers interesting possibilities for the development of high-level commands for robotic camera holders in laparoscopic surgery. We have developed a new method to detect instruments in laparoscopic images which uses information on the 3D position of the insertion point of an instrument into the abdominal cavity. This information strongly constrains the search for the instrument in each endoscopic image. Hence, the instrument can be detected in near real-time using shape considerations. Early results on laparoscopic images show that the method is rapid and robust in the presence of partial occlusion and smoke. Our first experiment on a cadaver validates our approach and shows encouraging results.

Robotic Partial Nephrectomy Versus Laparoscopic Cryoablation for the Small Renal Mass

BACKGROUND Open partial nephrectomy (OPN) remains the gold standard for treatment of small renal masses (SRMs). Laparoscopic cryoablation (LCA) has provided encouraging outcomes. Robotic partial nephrectomy (RPN) represents a new promising option but is still under evaluation. OBJECTIVE Compare the outcomes of RPN and LCA in the treatment of patients with SRMs. DESIGN, SETTING, AND PARTICIPANTS We retrospectively analyzed the medical charts of patients with SRMs (≤4cm) who underwent minimally invasive nephron-sparing surgery (RPN or LCA) in our institution from January 1998 to December 2010. INTERVENTION RPN and LCA. MEASUREMENTS Perioperative complications and functional and oncologic outcomes were analyzed. RESULTS AND LIMITATIONS A total of 446 SRMs were identified in 436 patients (RPN, n=210; LCA, n=226). Patients undergoing RPN were younger (p<0.0001), had a lower American Society of Anesthesiologists score (p<0.001), and higher baseline preoperative estimated glomerular filtration rate (eGFR) (p<0.0001). Mean tumor size was smaller in the LCA group (2.2 vs 2.4cm; p=0.004). RPN was associated with longer operative time (180 vs 165min; p=0.01), increased estimated blood loss (200 vs 75ml; p<0.0001), longer hospital stay (72 vs 48h; p<0.0001), and higher morbidity rate (20% vs 12%, p=0.015). Mean follow-ups for RPN and LCA were 4.8 mo and 44.5 mo, respectively (p<0.0001). Local recurrence rates for RPN and LCA were 0% and 11%, respectively (p<0.0001). Mean eGFR decrease after RPN and LCA was insignificant at 1 mo, at 6 mo after surgery, and during last follow-up. Limitations include retrospective study design, length of follow-up, and selection bias. CONCLUSIONS Both techniques remain viable treatment options in the management of SRMs. A higher incidence of perioperative complications was found in patients undergoing RPN. However, the technique was not predictive of the occurrence of postoperative complications. Early oncologic outcomes are promising for RPN, which also seems to be associated with better preservation of renal function. Long-term follow-up and well-designed prospective comparative studies are awaited to corroborate these findings.

Renal Cell Carcinoma (RCC) in Patients With End-Stage Renal Disease Exhibits Many Favourable Clinical, Pathologic, and Outcome Features Compared With RCC in the General Population

BACKGROUND Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours. OBJECTIVE Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population. DESIGN, SETTING, AND PARTICIPANTS Twenty-four French university departments of urology participated in this retrospective study. INTERVENTION All patients were treated according to current European Association of Urology guidelines. MEASUREMENTS Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods. RESULTS AND LIMITATIONS The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥ 3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design. CONCLUSIONS RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.

A realistic deformable prostate phantom for multimodal imaging and needle-insertion procedures

PURPOSE Phantoms are a vital step for the preliminary validation of new image-guided procedures. In this paper, the authors present a deformable prostate phantom for use with multimodal imaging (end-fire or side-fire ultrasound, CT and MRI) and more specifically for transperineal or transrectal needle-insertion procedures. It is made of soft polyvinyl chloride (PVC) plastic and includes a prostate, a perineum, a rectum, a soft periprostatic surrounding and embedded targets for image registration and needle-targeting. Its main particularity is its realistic deformability upon manipulation. METHODS After a detailed manufacturing description, the imaging and mechanical characteristics of the phantom are described and evaluated. First, the speed of sound and stress-strain relationship of the PVC material used in the phantom are described, followed by an analysis of its storage, imaging, needle-insertion force, and deformability characteristics. RESULTS The average speed of sound in the phantom was measured to be 1380 ± 20 m/s, while the stress-strain relationship was found to be viscoelastic and in the range of typical prostatic tissues. The mechanical and imaging characteristics of the phantom were found to remain stable at cooler storage temperatures. The phantom had clearly distinguishable morphology in all three imaging modalities, with embedded targets that could be precisely segmented, resulting in an average US-CT rigid registration error of 0.66 mm. The mobility of the phantom prostate upon needle insertion was between 2 and 4 mm, with rotations between 0° and 2°, about the US probe head. CONCLUSION The phantoms characteristics compare favorably with in vitro and in vivo measurements found in the literature. The authors believe that this realistic phantom could be of use to researchers studying new needle-based prostate diagnosis and therapy techniques.

A 3-D Ultrasound Robotic Prostate Brachytherapy System With Prostate Motion Tracking

This paper describes a new 3-D ultrasound robotic prostate brachytherapy system. It uses a stationary 3-D ultrasound probe rigidly fixed to a robotic needle insertion mechanism. The novelty of the system is its ability to track prostate motion intraoperatively to allow the dose planning and needle trajectories or depths to be adapted to take into account these motions. Prostate tracking is done using a fast 3-D ultrasound registration algorithm previously validated for biopsy guidance. The 7-degree-of-freedom (7-DOF) robot and ultrasound probe are calibrated together with an accuracy of 0.9 mm, allowing the needles to be precisely inserted to the seed targets chosen in the reference ultrasound image. Experiments were conducted on mobile, deformable synthetic prostate phantoms using a prototype laboratory system. Results showed that, with prostate motions of up to 7 mm, the system was able to reach the chosen targets with less than 2-mm accuracy in the needle insertion direction. This measured accuracy included extrinsic measurement errors of up to 1.1 mm. A preliminary cadaver feasibility study was also described in preparation for more realistic experimentation of the system.

Development of miniaturized light endoscope-holder robot for laparoscopic surgery.

PURPOSE We have conducted experiments with an innovatively designed robot endoscope holder for laparoscopic surgery that is small and low cost. MATERIALS AND METHODS A compact light endoscope robot (LER) that is placed on the patients skin and can be used with the patient in the lateral or dorsal supine position was tested on cadavers and laboratory pigs in order to allow successive modifications. The current control system is based on voice recognition. The range of vision is 360 degrees with an angle of 160 degrees . Twenty-three procedures were performed. RESULTS The tests made it possible to advance the prototype on a variety of aspects, including reliability, steadiness, ergonomics, and dimensions. The ease of installation of the robot, which takes only 5 minutes, and the easy handling made it possible for 21 of the 23 procedures to be performed without an assistant. CONCLUSION The LER is a camera holder guided by the surgeons voice that can eliminate the need for an assistant during laparoscopic surgery. The ease of installation and manufacture should make it an effective and inexpensive system for use on patients in the lateral and dorsal supine positions. Randomized clinical trials will soon validate a new version of this robot prior to marketing.

Automatic detection of instruments in laparoscopic images: a first step towards high level command of robotized endoscopic holders

The tracking of surgical instruments offers interesting possibilities for the development of high level commands for robotized camera holders in laparoscopic surgery. We present a new method to detect instruments in laparoscopic images which uses information on the 3D position of the insertion point of an instrument in the abdominal cavity. This information strongly constrains the search for the instrument in each endoscopic image. Hence, the instrument can be detected thanks to shape considerations, which would otherwise not be feasible in near real time. Early results show that the method is rapid and robust to partial occlusion and smoke

Real-Time Robotic Transrectal Ultrasound Navigation During Robotic Radical Prostatectomy: Initial Clinical Experience

OBJECTIVE To describe a novel robotic transrectal ultrasound platform for real-time navigation during robot-assisted laparoscopic radical prostatectomy (RALP) and to report its early clinical application. METHODS Five men undergoing RALPs at our Institution agreed to participate in this Institutional Review Board-approved pilot study. All of them were eligible for a bilateral nerve sparing procedure. Before docking the da Vinci robot, a transrectal ultrasound tri-plane side-fire probe was placed. A modified ViKY Endoscope Holder was used during RALPs to move the probe thanks to a remote control placed under the console surgeons control during RALPs. During each procedure, attempt was made to estimate prostate volume, define 12 reference points, and to precisely identify location of the neurovascular bundles using Doppler ultrasound. The TilePro was used during the procedures to allow real-time ultrasound imaging to guide robotic instruments during dissection. RESULTS Median robotic transrectal ultrasound probe holder (R-TRUS) setup time was 11 minutes (interquartile range [IQR], 10-14). Prostate volume calculation, reference point definition, neurovascular bundle identification, and instrument tip visualization were successful in all men. In 1 patient with a large prostate (120 mL), R-TRUS was withdrawn during recto-prostatic dissection. There were no rectal injuries. CONCLUSION R-TRUS during RALPs is feasible and safe. It allows real-time TRUS navigation and guidance. Further studies are needed to evaluate its impact on oncological and functional outcomes.