Ketul Shah

Robotic radical prostatectomy: outcomes of 500 cases

To report the outcomes of 500 robotically assisted laparoscopic radical prostatectomies (RALPs), a minimally invasive alternative for treating prostate cancer.

Durability of the Next-generation Flexible Fiberoptic Ureteroscopes: A Randomized Prospective Multi-institutional Clinical Trial

OBJECTIVES To evaluate the durability of 4 next-generation flexible ureteroscopes in a randomized, multi-institutional, prospective study. METHODS Patients at 3 institutions were randomized to 1 of 4 flexible ureteroscopes: the Wolf Viper, Olympus URF-P5, Gyrus-ACMI DUR-8 Elite (DUR-8E), and Stryker FlexVision U-500. Each center used 1 scope from each manufacturer until it needed major repair (primary endpoint). Intraoperative data included total time of use, number of scope insertions through an access sheath, working time in the lower pole, number of insertions and total time for accessory instrumentation in the working channel, number of laser insertions through the working channel, and total laser energy used. RESULTS A total of 175 patients were randomized. The DUR-8E experienced early catastrophic failure (< or = 10 cases) at all 3 sites; however, this also occurred at 1 site each for the Stryker and Wolf scopes. The DUR-8E required major repair after the fewest average number of cases (5.3), the lowest average total time of usage (108 minutes), the fewest insertions through an access sheath (20.3), the shortest duration of laser firing (31.3 minutes), and the shortest instrument in the working channel time (224.7 minutes). As such, due to variation in durability within manufacturers, no differences could be demonstrated. Visibility ratings for the Wolf iper were significantly better than the DUR-8E (P = .034) and the Flexvision (P = .038). CONCLUSIONS The Wolf Viper, Olympus URF-P5, and Stryker Flexvision U-500 flexible ureteroscopes seem comparable with regard to durability. However, larger prospective registry-based studies are needed to document significant differences between them.

Robotic-assisted laparoscopic radical prostatectomy: The Ohio State University technique

Robotic radical prostatectomy is a new innovation in the surgical treatment of prostate cancer. The technique is continuously evolving. In this article we demonstrate The Ohio State University technique for robotic radical prostatectomy. Robotic radical prostatectomy is performed using the da Vinci surgical system. The video demonstrates each step of the surgical procedure. Preliminary results with robotic prostatectomy demonstrate the benefits of minimally invasive surgery while also showing encouraging short-term outcomes in terms of continence, potency and cancer control. Robotic radical prostatectomy is an evolving technique that provides a minimally invasive alternative for the treatment of prostate cancer. Our experience with the procedure now stands at over 1,300 cases.

The use of high resolution optical coherence tomography to evaluate robotic radical prostatectomy specimens.

OBJECTIVE Optical coherence tomography (OCT) is a unique technology, developed to provide high resolution, cross sectional images of human tissue. The objective of this study was to explore the feasibility of OCT for the evaluation of positive surgical margins and extra capsular extension in robotic prostatectomy specimens and compare it to histopathology. MATERIALS AND METHODS Radical prostatectomy was performed in 100 patients. Twenty OCT images of each specimen were taken from the base of the seminal vesicles (SV), apical and vesicle margins, peripheral and posterolateral area and any palpable nodule. Predictions were made regarding positive surgical margin, SV involvement, capsular invasion and compared with the final histopathology. RESULTS A total of 2000 OCT images were taken and analyzed. Out of 100 specimens, 85 had T2 disease, 15 had T3 disease with a median Gleasons score of 7 (range 6 to 9) and 10 had positive surgical margins. We predicted 21 specimens to have positive margins based on OCT images out of which 7 were truly positive and 14 were falsely positive. Based on OCT images, 79 specimens were predicted to have negative margins out of which 76 were truly negative and 3 were falsely negative. We found the sensitivity, specificity, positive predictive value and negative predictive value to be 70%, 84%, 33% and 96% respectively. CONCLUSION Our initial feasibility study established the template for the visual OCT characteristics of the prostate, SV and cancerous tissue. The negative predictive value of evaluating surgical margins was high.

Applications of robots in urology

During the last two decades the field of urology has seen a tremendous growth in minimally invasive surgery. Potential advantages with this shift toward laparoscopic surgery include smaller incisions, reduced blood loss, less post-operative pain with reduced intake of narcotics, shorter hospital stays, and faster recovery. Nephrectomy, adrenalectomy, pyeloplasty, and prostatectomy have all established themselves as procedures benefitting from minimally invasive surgery. Complex laparoscopic procedures, for example prostatectomy, have proven to be quite a daunting task, because of the steep learning curve for many urologists [1]. Factors limiting the performance of standard laparoscopic radical prostatectomy are counter-intuitive motion, the lack of depth perception secondary to 2D vision, and rigid instrumentation with only four degrees of surgical freedom. These factors hinder visualization, dissection, and suturing in small spaces [1]. Introduction of robotic technology into modern day surgery has removed many of these technical barriers and has the potential to facilitate the broad-based adoption of complex laparoscopic procedures. There are more than 400 robotic systems in the USA and over 30,000 robotic procedures have been performed (communication with Intuitive Surgical). Although, initially, the equipment was conceived for use in cardiac surgery, adoption has been strongest in urology. It seems that robotic surgery has been uniquely adapted to urology, especially prostatectomy, because of the unique advantage of miniature instruments in the pelvis. Although prostatectomy is the main use of robotic surgery in urology its use in other urologic procedures is expanding rapidly as surgeons become more adept with its use. We review the current status of robotic technology, the constraints to its use and the surgical applications of robotic technology in urology.

Robotic-assisted laparoscopic radical prostatectomy: a report of the current state

Cancer of the prostate is the most common malignancy diagnosed in the male genitourinary tract. Although a number of treatment options are available for early prostate cancer, the gold standard of treatment remains retropubic radical prostatectomy. However, robotic-assisted laparoscopic radical prostatectomy (RALP) has become a forerunner in treatment options, yielding comparable medium-term perioperative and functional outcomes. For this our team utilized MEDLINE, searching for publications on perioperative and functional outcomes related to robotic prostatectomy. Robotic-assisted prostatectomy has allowed urologists to enter the realm of minimally invasive surgery by incorporating open surgery maneuvers into a laparoscopic environment. To date, RALP perioperative and functional outcomes are comparable to the gold standard; the collection of long-term data is needed in order to establish its true efficacy.

Comparison of intraoperative outcomes using the new and old generation da Vinci® robot for robot-assisted laparoscopic prostatectomy

Study Type – Therapy (case series)

Prostatectomía radical asistida por robot: resultados funcionales

OBJECTIVES To present a contemporary review of the functional outcomes following robotic-assisted radical prostatectomy based on published postoperative erectile function and urinary continence data. METHODS A review of the available literature on Medline and PubMed databases was performed. RESULTS Factors affecting erectile function include age, preoperative SHIM scores, co-morbidities and nerve sparing techniques. Large robotic-assisted laparoscopic radical prostatectomy (RALP) series like the Vattikuti Institutes and Ohio State Universitys demonstrate early potency outcomes: 70% and 80% of patients, respectively, who underwent bilateral nerve sparing and had a pre-operative SHIM score > 17, regained potency after a follow-up of 12 months. This has also been reproduced by smaller series, where 43% of patients achieved potency within 3 months postop and 68%, 79% of patients who underwent unilateral or bilateral nerve sparing, respectively, were able to have intercourse with or without PDE5 inhibitors after 12 months follow-up. Postoperative continence rates after RALP for larger series are 76%-92% and 95. 2%-98% while that for smaller series range from 76% and 89% at 3 and 12 months, respectively. CONCLUSIONS RALP is a safe, minimally invasive procedure that produces functional outcomes comparable to contemporary results of both open and laparoscopic prostatectomy.

930 CLINICAL PATHWAY FOR DISCHARGE ON POSTOPERATIVE DAY ONE AFTER ROBOTIC PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: A potential benefit of minimally-invasive surgery is reduced hospital stay, but regardless of approach, the complexity of a procedure and potential complications can limit early discharge. Published lengths of stay after robotic partial nephrectomy (RPN) have not been significantly less than those after open surgery. We present a clinical pathway targeting discharge on postoperative day (POD) one after RPN attempting to take advantage of the potentially less morbid procedure with analysis of ability to adhere to the pathway. METHODS: We reviewed all patients undergoing RPN since institution of our clinical pathway. A total of four ports is used with specimen extraction typically at a periumbilical port site and bupivicaine injected at all incisions. Patients ambulate and take clear liquids the night of surgery. Intravenous narcotics are avoided with oral analgesics and ketorolac (renal function permitting) given for pain control. No stent is used and closed suction drains are avoided. The Foley catheter is removed and regular diet started the morning after surgery with discharge the same day. The pathway is used regardless of complexity of the resection. RESULTS: A total of 98 RPNs were performed in 90 consecutive patients with all placed on the pathway. Mean age was 57yrs (22–83yrs), mean BMI was 32kg/m2 (20–49kg/m2), and mean ASA score was 2.8. Mean and median tumor size were 2.9cm and 2.6cm (range, 0.4–9cm). Mean OR time was 198min and mean blood loss was 187mL with 2 transfusions (2%). Warm ischemia time overall was 11.6min (0–30.0min) and was 16.1min excluding off-clamp resections. Mean preoperative and discharge serum creatinine were 0.91mg/dL (0.43–2.79) and 1.15mg/dL (0.57–2.93), respectively. All patients ambulated the day of surgery, and none required intravenous narcotics. No stents were placed, and a JP drain was avoided in 82 patients (91%) with only one (1%) experiencing a minor urine leak managed with a Foley catheter for one week. Four ports were adequate in 75 patients (83%). Eighty-five of 90 patients (94%) were discharged on POD#1. Reasons for longer stay included pulmonary concerns, anemia, and negative exploratory laparotomy for suspected bowel injury in one patient each and patient preference in two. Only 4 of 85 patients discharged on POD#1 required readmission within 30 days of surgery (5%), including for fever, anorexia, ileus, and one at an outside facility for pneumonia. CONCLUSIONS: Discharge on POD#1 is feasible in most patients after RPN without increased complications and may represent an advantage over open surgery if such a clinical pathway is applied.

Nerve-sparing Techniques for Laparoscopic and Robot-assisted Radical Prostatectomy

The preservation of sexual potency after prostatectomy has always been the topic of much anxiety and debate. While cancer control and urinary continence are of supreme importance, the preservation of sexual function completes the trifecta that both patient and surgeon strive to achieve. Over the decades open nerve-sparing radical prostatectomy has continued to evolve from its early rudimentary beginnings into the more refined techniques that we see at present; however, while we have seen considerable advances in recent times, the limitations in visualization and dissection of the bundle have continued to provide a challenge to even the most experienced surgeon. The introduction of robotic assistance to modern laparoscopic surgery has provided many advantages, the two greatest being improved three-dimensional magnified vision and wristed instrumentation. These technical enhancements provide the surgeon with improved surgical tools that have the potential to facilitate a more precise surgical approach. One of the potential advantages during robotic prostatectomy is improving visualization, control, and dissection of the neurovascular bundle (NVB). In this chapter we present the pertinent anatomy and the various technical approaches to nerve sparing during robotic radical prostatectomy.