Mevlana Derya Balbay

Anesthetic considerations for robotic cystectomy: a prospective study.

BACKGROUND AND OBJECTIVES Robotic cystectomy is rapidly becoming a part of the standard surgical repertoire for the treatment of prostate cancer. Our aim was to describe respiratory and hemodynamic challenges and the complications observed in robotic cystectomy patients. PATIENTS Sixteen patients who underwent robotic surgery between December 2009 and January 2011 were prospectively enrolled. Main outcome measures were non-invasive monitoring, invasive monitoring and blood gas analysis performed at supine (T0), Trendelenburg (T1), Trendelenburg+pneumoperitoneum (T2), Trendelenburg-before desufflation (T3), Trendelenburg (after desufflation) (T4), and supine (T5) positions. RESULTS There were significant differences between T0-T1 and T0-T2 with lower heart rates. The mean arterial pressure value at T1 was significantly lower than T0. The central venous pressure value was significantly higher at T1, T2, T3, and T4 than at T0. There was no significant difference in the PET-CO2 value at any time point compared with T0. There were no significant differences in respiratory rate at any time point compared with T0. The mean f values at T3, T4, and T5 were significantly higher than T0. The mean minute ventilation at T4 and T5 were significantly higher than at T0. The mean plateau pressures and peak pressures at T1, T2, T3, T4, and T5 were significantly higher than the mean value at T0. CONCLUSIONS Although the majority of patients generally tolerate robotic cystectomy well and appreciate the benefits, anesthesiologists must consider the changes in the cardiopulmonary system that occur when patients are placed in Trendelenburg position, and when pneumoperitoneum is created.

Robot-assisted nerve-sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases.

Study Type – Therapy (case series)

Low ERCC1 expression is associated with prolonged survival in patients with bladder cancer receiving platinum-based neoadjuvant chemotherapy

PURPOSE Excision repair cross-complementation group 1 enzyme (ERCC1) plays a key role in the removal of platinum induced DNA adducts and cisplatin resistance. Prognostic role of ERCC1 expression in the neoadjuvant setting in bladder cancer has not been reported before. We evaluated the prognostic role of ERCC1 expression in bladder cancer receiving platinum-based neoadjuvant chemotherapy. MATERIALS AND METHODS Thirty-eight patients with muscle invasive bladder cancer who received neoadjuvant platinum-based chemotherapy were included. Clinical and histopathologic parameters along with immunohistochemical ERCC1 staining were examined and correlated with response rates and survival. RESULTS Pathologic complete response rates were similar between patients with low and high ERCC1 expression. Median disease-free survival (DFS) was 9.3 vs. 20.5 months (P = 0.186) and median overall survival (OS) was 9.3 vs. 26.7 months (P = 0.058) in patients with high ERCC1 expression compared with those with low expression, respectively. In multivariate Cox regression analysis: pathological complete response (pCR) after chemotherapy (hazard ratio (HR) 0.1, 95% CI 0.012-0.842, P = 0.034) and high ERCC1 expression (HR 3.7, 95% CI 1.2-11.2, P = 0.019) were significantly associated with DFS. Patient age (>60 vs. ≤ 60 years) (HR 3.4, 95% CI 1.2-9.4, P = 0.018), the presence of pCR (HR 0.11, 95% CI 0.014-0.981, P = 0.048) and high ERCC expression (HR 6.1, 95 CI 1.9-19.9, P = 0.002) were significantly associated with OS. CONCLUSIONS Our results showed that high ERCC1 expression was independently associated with shorter disease-free and overall survival in patients with bladder cancer who received neoadjuvant platinum-based chemotherapy. ERCC1 may represent a potential predictive marker for platinum-based treatment in bladder cancer.

Robot-assisted laparoscopic nerve-sparing radical cystoprostatectomy with bilateral extended lymph node dissection and intracorporeal studer pouch construction: outcomes of first 12 cases.

PURPOSE We report our initial experience with robot-assisted laparoscopic neurovascular bundle (NVB) sparing radical cystoprostatectomy (RALRC), bilateral extended lymph node dissection (BELND) with intracorporeal Studer pouch construction for invasive bladder cancer. PATIENTS AND METHODS After initially performing >50 cases of robot-assisted laparoscopic radical prostatectomies (RALRP), between December 2009 and April 2010, we performed 12 RALRC procedures with BELND. Bilateral (n=10) and unilateral (n=1) intrafascial NVB preservation was performed in 11 patients; nonnerve-sparing RALRC was performed in 1 patient. RESULTS Patient characteristics and surgical and postoperative parameters were mean patient age (y): 60 (43-80); American Society of Anesthesiologists score: 2 (1-3); body mass index (kg/m(2)): 24.5 (19.3-31.2); preoperative International Index of Erectile Function (IIEF) score: 25 (5-65); operative time (h): 10 (8.1-11.5); intraoperative blood loss (mL): 455 (100-700); lymph node (LN) yield: 21.3 (8-38); hospital stay (d): 10.7 (9-16); lodge drain removal (d): 10 (9-15). Five patients received neoadjuvant chemotherapy. Surgical margins were negative in all patients. Postoperative pathologic stages were: pT(0) (n=2), pT(1) (n=1), pT(2a) (n=2), pT(2b) (n=2), pT(3a) (n=4), and pT(4a) (n=1). Positive LNs and incidental prostate cancer were detected in five and three patients, respectively. Perioperative death rate was zero. Right external iliac vein injury occurred in one patient during the performance of BELND; surgery was converted to an open procedure and the injury was repaired. Colonic fistula developed in one patient at postoperative day 40; the patient died from cardiac disease at day 60. At a mean follow-up of 7.1 ± 2.3 months, three patients died from metastatic disease. Of the available seven patients, six were fully continent and one had mild daytime incontinence. CONCLUSIONS Although RALRC with bilateral intrafascial NVB preservation, BELND, and intracorporeal Studer pouch formation is a complex procedure, it can be performed with excellent short-term surgical and pathological outcomes and satisfactory functional results after considerable experience gained with RALRP procedures.

Early Oncologic Failure after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

Purpose: We sought to investigate the prevalence and variables associated with early oncologic failure. Materials and Methods: We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot‐assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot‐assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan‐Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival. Results: A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38–5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00–6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21–3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001). Conclusions: The incidence of early oncologic failure following robot‐assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot‐assisted radical cystectomy.

Robot-assisted radical cystectomy and intracorporeal neobladder formation: on the way to a standardized procedure

BackgroundRobot-assisted radical cystectomy (RARC) with intracorporeal diversion has been shown to be feasible in a few centers of excellence worldwide, with promising functional and oncologic outcomes. However, it remains unknown whether the complexity of the procedure allows its duplication in other non-pioneer centers. We attempt to address this issue by presenting our cumulative experience with RARC and intracorporeal neobladder formation.MethodsWe retrospectively identified 62 RARCs in 50 men and 12 women (mean age 63.6 years) in two tertiary centers. Intracorporeal Studer neobladders were created, duplicating the steps of standard open surgery. Perioperative and postoperative variables and complications were analyzed using standardized tools. Functional and oncological results were assessed.ResultsThe mean operative time was 476.9 min (range, 310 to 690) and blood loss was 385 ml (200 to 800). The mean hospital stay was 16.7 (12 to 62) days with no open conversion. Perioperative complications were grade II in 15, grade III in 11, and grade IV in 5 patients. The mean nodal yield was 22.9 (8 to 46). Positive margins were found in in 6.4%. The 90- and 180-day mortality rates were 0% and 3.3%. The average follow-up was 37.3 months (3 to 52). Continence was achieved in 88% of patients. The cancer-specific survival rate and overall survival rate were 84% and 71%, respectively.ConclusionsA RARC with intracorporeal neobladder creation is safe and reproducible in ‘non-pioneer’ tertiary centers with robotic expertise with acceptable operative time and complications. Further standardization of RARC with intracorporeal diversion is a prerequisite for its widespread use.

Delayed massive hemorrhage due to external iliac artery pseudo- aneurysm and uretero-iliac artery fistula following robotic radical cystectomy and intracorporeal Studer pouch reconstruction: Endovascular management of an unusual complication

We report a very unusual complication of uretero-iliac artery fistula that developed following robotic radical cystectomy (RARC), bilateral extended pelvic lymph node dissection and intracorporeal Studer pouch reconstruction. Our patient was a 54-year-old male who was admitted 1 month after undergoing robotic surgery due to intermittently occurring massive transurethral bleeding necessitating blood transfusion that stopped by itself. Angiography showed a right external iliac artery pseudo-aneurysm and a fistula tract between the pseudo-aneurysm and Wallace type ureteral anostomosis that was successfully treated by an angiographic endovascular stent insertion at this level. Uretero-iliac artery fistula might occur following RARC, bilateral extended pelvic lymph node dissection and intracorporeal Studer pouch reconstruction leading to intermittently massive transurethral bleeding. Angiography and stenting are important for diagnosis and successful treatment of this rare entity.

Robot–assisted radical cystectomy and intracorporeal urinary diversion – safe and reproducible?

Introduction Robot–assisted radical cystectomy (RARC) plus intracorporeal urinary diversion is feasible. Few centers worldwide demonstrated comparable functional and oncologic outcomes. We reported a large series of RARC and intracorporeal diversion to assess its feasibility and reproducibility. Material and methods We identified 101 RARCs in 82 men and 19 women (mean age 68.3 years) from October 2009 to October 2014. The patients underwent RARC and pelvic lymphadenectomy followed by intracorporeal urinary diversion (ileal conduit/ neobladder). Out of the 101 patients, 28 (27.7%) received intracorporeal ileal conduits and 73 (72.3%) intracorporeal neobladders. Studer pouch was performed in all the patients who underwent intracorporeal neobladder formation. Perioperative, functional and oncologic results including CSS and OS are reported. Results Mean operative time was 402.3 minutes (205–690) and blood loss was 345.3 ml (50–1000). The mean hospital stay was 17.1 days (5–62). All the surgeries were completed with no open conversion. Minor complications (Grade I and II) were reported in 27.7% of patients while major complications (grade III and above) were reported in 36.6% of patients. The mean nodal yield was 20.6 (0–46). Positive ureteric margins were found in 8.9% of patients. The average follow–up was 27.5 months (1–52). Daytime continence could be achieved in 89.2% of patients who underwent intracorporeal neobladder. The 3–year cancer specific survival (CSS) and overall survival (OS) was 80.2% and 69.8% respectively. Conclusions RARC with intracorporeal diversion is safe and reproducible in ‘non–pioneer’ tertiary centers with robotic expertise having acceptable operative time and complications as well as comparable functional and oncologic outcomes.

Ureteric duplication is not a contraindication for robot-assisted laparoscopic radical cystoprostatectomy and intracorporeal Studer pouch formation.

The authors found that duplicated ureters was not a contraindication to robot-assisted laparoscopic radical cystoprostatectomy in this case.

Outcomes of robot-assisted laparoscopic radical prostatectomy in high-risk prostate cancer patients: experience in 34 patients with oncologic and functional outcomes

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