Juan Garisto

Robotic Single-port Partial Prostatectomy for Anterior Tumors: Transvesical Approach

OBJECTIVEnTo evaluate the feasibility of a single-port transvesical robotic approach for anterior partial prostatectomy in a cadaver model.nnnMATERIALS AND METHODSnThe cadavers were placed in a lithotomy position and secured to the operating table. A 3-cm midline incision was made in the suprapubic skin fold. After opening the Retzius space, a single-port mini device (GelPOINT, Rancho Margarita, CA) was introduced percutaneously directly into the bladder. The da Vinci Si robotic platform (Intuitive Surgical, Sunnyvale, CA) was docked to the GelPOINT by inserting 2 8-mm (robotic arms) and 1 12-mm (camera) trocar through the GelSeal Cap. The surgical steps for en bloc anterior prostatectomy were performed in the following order: (1) retrograde dissection of transition zone at the bladder neck, (2) lateral excision of the peripheral zone, and (3) urethrovesical anastomosis. Primary outcomes such as intraoperative complications, rate of conversion to standard techniques, and operative times were recorded.nnnRESULTSnSingle-port transvesical robotic approach for anterior partial prostatectomy was technically completed in 2 male cadavers. Both cases were completed successfully using the da Vinci Si surgical system without conversion or the need for additional ports. There were no intraoperative complications. The total operative time was 124.1 and 81.3u2009minutes. Step-specific times are listed in Tablexa01.nnnCONCLUSIONnTransvesical robotic partial prostatectomy is technically feasible using a single-port approach in a preclinical model. Further studies are needed for evaluation on patients with anterior localized prostate cancer. Prospective comparison with standard surgical techniques and focal therapy are warranted. Refinement of this technique may potentially expand the role of single-site surgery in the clinical practice.

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T2 Renal Tumors: A Multicenter Analysis (ROSULA Collaborative Group)

BACKGROUNDnWhile partial nephrectomy (PN) represents the standard surgical management for cT1 renal masses, its role for cT2 tumors is controversial. Robot-assisted PN (RAPN) is being increasingly implemented worldwide.nnnOBJECTIVEnTo analyze perioperative, functional, and oncological outcomes of RAPN for cT2 tumors.nnnDESIGN, SETTING, AND PARTICIPANTSnRetrospective analysis of a large multicenter, multinational dataset of patients with nonmetastatic cT2 masses treated with robotic surgery (ROSULA: RObotic SUrgery for LArge renal mass).nnnINTERVENTIONnRobotic-assisted PN.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnPatients demographics, lesion characteristics, perioperative variables, renal functional data, pathology, and oncological data were analyzed. Univariable and multivariable regression analyses assessed the relationships with the risk of intra-/postoperative complications, recurrence, and survival.nnnRESULTS AND LIMITATIONSnA total of 298 patients were analyzed. Median tumor size was 7.6 (7-8.5) cm. Median RENAL score was 9 (8-10). Median ischemia time was 25 (20-32) min. Median estimated blood loss was 150 (100-300) ml. Sixteen patients had intraoperative complications (5.4%), whereas 66 (22%) had postoperative complications (5% were Clavien grade ≥3). Multivariable analysis revealed that a lower RENAL score (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.21-0.65, p=0.02) and pathological pT2 stage (OR 0.51, 95% CI 0.12-0.86, p=0.001) were protective against postoperative complications. A total of 243 lesions (82%) were malignant. Twenty patients (8%) had positive surgical margins. Ten deaths and 25 recurrences/metastases occurred at a median follow-up of 12 (5-35) mo. At univariable analysis, higher pT stage was predictive of a likelihood of recurrences/metastases (p=0.048). While there was a significant deterioration of renal function at discharge, this remained stable over time at 1-yr follow-up. The main limitation of this study is its retrospective design.nnnCONCLUSIONSnRAPN in the setting of select cT2 renal masses can safely be performed with acceptable outcomes. Further studies are warranted to corroborate our findings and to better define the role of robotic nephron sparing for this challenging indication.nnnPATIENT SUMMARYnThis report shows that robotic surgery can be used for safe removal of a large renal tumor in a minimally invasive fashion, maximizing preservation of renal function, and without compromising cancer control.

Different approaches to the prostate: The upcoming role of a purpose-built single-port robotic system

Abstract With the aim of minimising the patient’s postoperative pain, expediting recovery and improving cosmesis, the idea of performing a laparoscopic procedure through a single abdominal incision was introduced. In the present report, we describe five different access routes to the prostate that may be at the surgeon’s disposal with the potential of decreasing patient’s perioperative morbidity. Robotic radical prostatectomy has been refined and became a standard of care in surgery for localised prostate cancer. The advent of single-port robotic surgery has prompted the re-discovery of different access routes to the prostate and ideally all of them are feasible. The potential for avoiding the abdominal cavity will decrease the surgical morbidity and minimise the surgical dissection. In the near future, each of the described approaches could be chosen on the basis of the patient’s preoperative comorbidities, body habitus, anatomy, and disease characteristics and location.

Robotic versus open partial nephrectomy for highly complex renal masses: Comparison of perioperative, functional, and oncological outcomes

INTRODUCTIONnWe aimed to compare perioperative, functional and oncological outcomes between robot-assisted partial nephrectomy (RAPN) and open partial nephrectomy (OPN) for highly complex renal tumors (R.E.N.A.L. nephrometry Score > 9).nnnMETHODSnA retrospective review of 1,497 patients who consecutively underwent partial nephrectomy at a single academic tertiary center between 2008 and 2016 was performed to get data about patients who underwent RAPN and OPN for renal masses with RENAL score > 9. Baseline, perioperative, functional, and oncological outcomes were compared.nnnRESULTSnTwo hundred and three RAPN and 76 OPN were extracted. Patients demographics and tumors characteristics were comparable between the groups. Blood loss (200 vs. 300 cc, P < 0.0001), intraoperative transfusion rates (3% vs. 15.8%, P < 0.001), and length of stay (3 vs. 5 days, P < 0.01) were lower for RAPN. A significant decrease in estimated glomerular filtration rate was observed from preoperative to postoperative period, regardless the approach (OPN, Pu202f=u202f0.026 vs. RAPN, Pu202f=u202f0.014). Conversion to radical nephrectomy was 7.8% and 5.9% for OPN and RAPN, respectively. At multivariable regression, open approach was predictive of intraoperative transfusion and reoperation. Overall actuarial rate of recurrence or metastasis was 4.3%, with 3 cancer-related deaths occurring after a median follow-up of 25 months. No differences were found between the groups.nnnCONCLUSIONnIn our large single-institutional series of patients who underwent partial nephrectomy for highly complex renal tumors, robotic approach appeared to be a valuable alternative to OPN, with the advantages of reduced blood loss, ischemia time, transfusions rate, and length of stay.

Cold Versus Warm Ischemia Robot-Assisted Partial Nephrectomy: Comparison of Functional Outcomes in Propensity-Score Matched “At Risk” Patients

OBJECTIVESnTo compare functional outcomes of warm ischemia RPN (wRPN) to cold ischemia RPN (cRPN) in at risk patients.nnnMATERIALS AND METHODSnRetrospective review of institutional database queried for all patients who underwent cRPN/wRPN (January 2007-December 2016). For the study purpose, patients with solitary kidney and/or history of partial nephrectomy and/or multiple tumors and/or preoperative estimated Glomerular Filtration Rate (eGFR) <60u2009mL/minute were extracted. To reduce inherent biases, groups were matched on key variables related to renal function through a greedy matching algorithm with no replacement. Renal functional outcomes were evaluated by eGFR drops at 1-3 days and at 1, 3, 6, and 12 months postoperatively. A linear mixed effects model was used to assess eGFR at each follow-up who received either cRPN or wRPN. Follow-up was treated as a factor variable to account for nonlinear time trends. Contrast analysis was used to compare cRPN vs wRPN groups at each follow-up, using Sidak-Holm p-value adjustments for multiple comparisons.nnnRESULTSnOut of 19 cRPN patients and 279 wRPN patients, 14 cRPN patients were finally matched 1:1 with no replacement to 14 wRPN. There was no significant difference in preoperative eGFR for matched patients undergoing cRPN vs wRPN. Since the first postoperative day, cRPN patients had higher eGFR. The difference was statistically significant since the third month postoperatively (mean differenceu2009=u200918.201, 95% confidence interval [CI]: 1.930-34.472) and remained at both the sixth month (mean differenceu2009=u200918.839, 95% CI: 2.568-35.109) and the 12th month (mean differenceu2009=u200921.277, 95% CI: 5.006-37.547) follow-up.nnnCONCLUSIONSnAccounting for unmodifiable and modifiable factors, in a cohort of highly selected patients at risk for postoperative significant decline in renal function after RPN, renal functional outcomes appear to be superior with cold ischemia technique.

Novel System for Robotic Single-port Surgery: Feasibility and State of the Art in Urology

Robotic urology has evolved in parallel with the development of new robotic systems. A recently conceived robotic platform, specifically designed for single-port (SP) surgery, has reignited the interest for the approach. In this review, the evolution of robotic SP surgery was analyzed. Since the first published experience with a robot-assisted SP urological procedure in 2010, despite technical adjustments, robotic SP has remained with limited diffusion. However, the limitations of the available instrumentation are going to be softened with an upcoming next-generation robotic platform. Indeed, a purpose-built SP platform is being tested. The new purpose-built SP robotic system seems to represent a step forward. Based on the preliminary available experience, it facilitates the SP approach being the platform specifically designed for SP surgery. The novel SP robot could sponsor the alternative approaches to common urological interventions, allowing for potentially further minimization of the invasiveness of robotic surgery. Clinical trials will be awaited when this technology is commercially available. PATIENT SUMMARY: A novel robotic platform has been designed to be used for single-port surgery. With this particular approach, the surgery is performed through a single skin incision. Alternative access for common urological interventions will be sponsored by the new robotic platform, allowing for further reduction of the invasiveness of robotic surgery.

Concurrent Robotic Pyelolithotomy and Partial Nephrectomy: Tips and Tricks

OBJECTIVEnWith the evolution of robot-assisted surgery in the urology field, this technology is being applied to treat many genitourinary conditions.1 Although incidence of urolithiasis and renal neoplasm has increased, encountering both entities in a single kidney is noteworthy. Our video exhibits the concurrent management of a renal calculus and an ipsilateral renal neoplasm using a robotic platform.nnnMATERIALS AND METHODSnA 53-year-old man was diagnosed with a 1.7-cm left renal pelvis calculus and a 4.7-cm enhancing ipsilateral upper pole renal mass (R.E.N.A.L score 8a) after an episode of flank pain. After reviewing preoperative imaging, a single-setting approach using a robotic platform was planned. Main steps of our robotic technique on the case included (1) kidney defatting and mobilization, (2) hilum and ureter dissection up to the renal pelvis, (3) intraoperative ultrasound for tumor demarcation and stone localization, (4) anterior robotic pyelolithotomy,2 (5) double J stent placement and pyelotomy closure, (6) excision of renal mass, and (7) renorrhaphy. Perioperative outcomes were recorded.nnnRESULTSnThe operative time was 180 minutes and the estimated blood loss was 100u2009mL. Warm ischemia time was 17 minutes. There were no intra- or postoperative complications. The patient was discharged home on postoperative day 3. Final pathology reported a 3.4-cm mass consistent with a clear cell renal carcinoma, with a tumor, nodes, metastases (TNM) staging pT1aNx and negative surgical margin. The double J stent was removed after 4 weeks, and the patient remained asymptomatic at 1 month postoperatively.nnnCONCLUSIONnPyelolithotomy and robotic partial nephrectomy can be performed effectively when treating patients with concurrent kidney mass and renal stone using the same surgical access. This minimally invasive approach should be contemplated as an option when managing patients with both conditions in an ipsilateral kidney. Furthermore, it will diminish the necessity of various surgeries while preserving renal function and maintaining oncological outcomes. We underline that the association of both procedures increases the likelihood of technical complications and risk for clot-related or stone-related ureteral obstruction, infection, and urine leak.

Infrared Light Structured Sensor Three-dimensional Approach to Estimate Kidney Volume: A Validation Study

OBJECTIVEnTo validate a new procedure for the three-dimensional estimation of total renal parenchyma volumeusing a structured-light infrared laser sensor.nnnMETHODSnTo evaluate the accuracy of the sensor for assessing renal volume, we performed 3 experiments. Twenty freshly excised porcine kidneys were obtained. Experiment A, the water displacement method was used to obtain a determination of the renal parenchyma volume after immersing every kidney into 0.9% saline. Thereafter a structured sensor (Occipital, San Francisco, CA) was used to scan the kidney. Kidney sample surface was presented initially as a mesh and then imported into MeshLab (Visual Computing Lab, Pisa, Italy) software to obtain the surface volume. Experiment B, a partial excision of the kidney with measurement of the excised volume and remnant was performed. Experiment C, a renorrhaphy of the remnant kidney was performed then measured. Bias and limits of agreement (LOA) were determined using the Bland-Altman method. Reliability was assessed using the intraclass correlation coefficient (ICC).nnnRESULTSnExperiment A, the sensor bias was -1.95mL (LOA: -19.5 to 15.59, R2u202f=u202f0.410) with slightly overestimating the volumes. Experiment B, remnant kidney after partial excision and excised kidneyvolume were measured showing a sensor bias of -0.5mL (LOA -5.34 to 4.20, R2= 0.490) and -0.6mL (LOA: -1.97.08 to 0.77, R2u202f=u202f0.561), respectively. Experiment C, the sensor bias was -0.89mL (LOA -12.9 to 11.1, R2= 0.888). ICC was 0.9998.nnnCONCLUSIONnThe sensor is a reliable method for assessing total renal volume with high levels of accuracy.

Robotic Partial Nephrectomy for Complex Hilar Tumors: Tips and Tricks

OBJECTIVEnTo report our step-by-step technique and provide tips and tricks for robotic partial nephrectomy (RPN) in a highly complex renal mass. Robotic surgery has widened the indications of the conservative treatment for renal masses. With increasing experience, larger deeply infiltrative tumors, or tumors involving the renal hilum can be treated with robotic partial nephrectomy.nnnMATERIALS AND METHODSnA 78-year-old male came to our attention for a complex right renal mass. Past medical history included severe hypertension and a myocardial infarction with subsequent stent placement in 2014. Baseline renal function assessed by serum creatinine was 0.93 mg/dl. The preoperative computed tomography scan and magnetic resonance showed a right enhancing posterior renal mass, 7.6 cm in diameter, cT2a, and RENAL score 12. The patient was scheduled for robotic partial nephrectomy. Transperitoneal approach with three arms robotic configuration was chosen.nnnRESULTSnOperative time including robots docking was 195 minutes. Warm ischemia time was 19 minutes. Blood losses were negligible, with no transfusions required. Serum creatinine at discharge was 1.15 mg/dl. Final pathology revealed a clear cell renal cell carcinoma, pT3b, and ISUP grade 3, involving the sinus fat and the renal vein. Surgical margins were negative.nnnCONCLUSIONnRobotic partial nephrectomy can be successfully performed in cases of completely endophytic central, hilar masses. Consistent experience is needed before embarking on this surgery. Future studies are needed to determine the long-term outcomes for partial nephrectomy for these complex tumors.

Minimally Invasive Management of Ureteral Distal Strictures: Robotic Ureteroneocystostomy With a Bilateral Boari Flap

OBJECTIVEnTo describe robotic ureteroneocystostomy performed by bilateral Boari flap.nnnMETHODSnAn 82-year-old female with bilateral mid ureteral strictures secondary to uterine cancer treated with radiation was managed with ureteral stenting and bilateral nephrostomy tubes. Nevertheless, patient had severe colic and recurrent urinary tract infections and thus agreed to undergo bilateral robotic ureteral reconstructive surgery. Patient positioning and ports placement were similar to those of robotic prostatectomy. Ureters were divided at the level of the common iliac bifurcation and mobilized proximally. Strictures were excised and ureters were spatulated. After the bladder was dropped from the abdominal wall, a bladder flap was created with a broad base to ensure adequate blood supply. The ureteral anastomosis to the bladder flap was started using 3-0 Vicryl interrupted sutures to secure the posterior ureter to the bladder flap. The flap was then bisected in the midline to create a tension-free anastomosis. The ureteral anastomosis was completed over a double J ureteral stent. The wings of the bisected bladder flap were reapproximated with a 3-0 barbed suture to form a Y bladder configuration. Procedures were done bilaterally. The remainder of the cystotomy was closed with barbed suture. The bladder was tested for leakages and a drain was placed.nnnRESULTSnBlood loss was 50 mL. The patient recovered uneventfully and was discharged on postoperative day 4 with nephrostomy tubes and Jackson-Pratt drain removed prior to discharge. Follow-up cystogram revealed no leakage and bilateral reflux in the reconstructed bladder. Ureteral stents were removed 4 weeks postoperatively. Follow-up for these patients is recommended with either a renal scan or CT scan with delayed imaging. For this patient with severe chronic kidney disease, she unfortunately could not receive intravenous contrast and renal scan proved unreliable. Therefore, our follow-up was performed on the basis of her renal function (creatinine) which remained stable without nephrostomies or ureteral stents. Postoperatively, the patient did not complain of de novo lower urinary tract symptoms nor did she require anticholinergics.nnnCONCLUSIONnRobotic bilateral Boari flap is feasible for patients with bilateral distal ureteral strictures. Further studies are needed to assess long-term outcomes. Given the significant degree of bladder reconstruction required for this procedure, we recommend an assessment of bladder capacity preoperatively in the form of a gravity cystogram or video urodynamics.