Omer Burak Argun

The incidence and sequela of lymphocele formation after robot-assisted extended pelvic lymph node dissection.

To determine an accurate incidence of lymphocele formation and its sequela after robot‐assisted radical prostatectomy (RARP) and extended lymph node dissection (eLND) in a contemporary prostate cancer cohort.

Radical Nephroureterectomy Without Patient or Port Repositioning Using the Da Vinci Xi Robotic System: Initial Experience

OBJECTIVE To report our initial experience on robot-assisted radical nephroureterectomy, using the da Vinci Xi robotic system without patient or port repositioning. MATERIALS AND METHODS The patients were in a modified flank position. A Bugbee electrode was used to cauterize and mark the ureteral orifice, aiding in the final robotic excision of the distal ureter. For the first step of the procedure, the second robotic arm holds the scope, the fourth robotic arm holds Port #1 (monopolar curved scissors), the first robotic arm holds Port #2 (Fenestrated bipolar forceps), and the third robotic arm holds Port #4 (Prograsp forceps). After completion of nephrectomy, all robotic arms were released and reconfigured. In the new setting, the third robotic arm and second robotic arm were switched between the camera port and the fourth port. The first port remained working with the monopolar curved scissors whereas Prograsp forceps was moved to the second port and fenestrated bipolar forceps was moved to the third port. RESULTS Two patients underwent 2 successful radical nephroureterectomies with the above-mentioned technique. The console time for the first patient was 150 minutes whereas the estimated blood loss was 200 mL. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization time and catheter removal time were 3 days for both patients and no complications were observed. CONCLUSION The use of the da Vinci Xi robotic system enabled us to perform both nephrectomy and distal ureterectomy and/or bladder cuff excision without any repositioning of the patient or trocars.

Robot-Assisted Bladder Diverticulectomy with Concurrent Management of Bladder Outlet Obstruction

Introduction: Robot-assisted bladder diverticulectomy (RABD) through a technique for easier identification of diverticulum along with concomitant management of bladder outlet obstruction (BOO) utilizing a combination of transurethral prostatectomy (TUR-P) and photoselective vaporization of prostate (PVP) is presented. Materials and Methods: Between 2008 and 2015, 9 patients underwent RABD with concurrent treatment of BOO. Diverticula were identified by a technique of catheterizing the diverticulum and the bladder simultaneously and individually. Results: Mean patient age was 62 ± 9.8 and prostate volume was 70 ± 26 ml. Mean time for endourological procedure was 77 ± 35, mean console and total operative times were 108 ± 38 and 186 ± 56 min, respectively. Mean estimated blood loss was 71 ± 37 ml. All diverticula were excised and BOO treated successfully. Bladder irrigation was not necessary in any patient. Mean hospitalization and catheter removal time was 5 ± 3 and 8 ± 3 days, respectively. No complications were observed. Conclusions: BOO is the main cause of acquired bladder diverticula and is largely due to benign prostatic hyperplasia. Concomitant performance of TUR-P and PVP along with RABD is feasible and safe. Individual catheterization of the diverticulum and bladder facilitates the identification of diverticulum even in the presence of multiple diverticula.

A prospective comparative analysis of robot-assisted vs open simple prostatectomy for benign prostatic hyperplasia

To report the first prospective comparative analysis of robot‐assisted (RASP) vs open simple prostatectomy (OSP) for large prostate glands.

Intra-surgical total and re-constructible pathological prostate examination for safer margins and nerve preservation (Istanbul preserve)

PURPOSE To demonstrate a novel frozen section analysis technique during robot assisted radical prostatectomy with 2 distinct advantages: evaluation of the entire circumference and easier reconstruction for whole mount evaluation. MATERIAL AND METHODS Istanbul Preserve was performed on patients who underwent robotic prostatectomy with nerve sparing between 10/2014 and 7/2016. Gland was sectioned at 3-4mm intervals from apex to bladder neck. Entire tissue representing margins (except for the most anterior portion) was circumferentially excised and microscopically analyzed. In margin positivity, approach was individualized based on extent of positive margin and Gleason pattern. A matched cohort was established for comparison. Retrospective analysis of a prospectively maintained database was performed. Impact of FSA on PSM rate was primarily assessed. RESULTS Data on 170 patients was analyzed. Positive surgical margin was reported in 56(33%) on frozen section. Neurovascular bundle was partially or totally resected in 79% and 18%. Conversion of positive margin to negative was achieved in 85%. Overall positive margin rate decreased from 22.5% to 7.5%. Nerve sparing increased from 87% to 93%. Location of positive margin at frozen was at the neurovascular bundle area in 39%; thus Istanbul Preserve detected 61% additional margin positivity compared to other techniques. Reconstruction for whole mount was easy. CONCLUSION Istanbul Preserve is a novel technique for intraoperative FSA during RARP allowing for microscopic examination of the entire prostate for margin status and easy re-construction for whole mount examination. It guarantees safer margins together with increased rate of nerve sparing.

Robot-Assisted Partial Nephrectomy for T1b Tumors: Strict Trifecta Outcomes

Background and Objectives: “Trifecta” in partial nephrectomy consists of negative surgical margins, minimal renal function decrease and absence of complications. In the present article, our single-center robot-assisted partial nephrectomy (RAPN) experience in T1b renal masses is reported in terms of strict Trifecta outcomes. Methods: This is a retrospective analysis of patients with a tumor diameter between 4 and 7 cm (stage T1b), who underwent RAPN by a single surgeon. Preoperative, intraoperative, and postoperative data were recorded and analyzed to evaluate short-term functional and oncologic outcomes. Patients with absence of grade ≥ 2 Clavien-Dindo complications, warm ischemia time (WIT) ≤25 minutes, ≤15% postoperative estimated glomerular filtration rate (eGFR) decrease and negative surgical margins were reported to achieve strict Trifecta outcomes. P < .05 was indicated statistically significant. Results: A total of 150 patients underwent RAPN, and 50 patients were identified with tumor size between 4 and 7 cm. Mean WIT was 20.8 ± 6.2 minutes and mean estimated blood loss (EBL) was 269 ± 191 mL. Surgical margins were negative in all patients. Eleven patients (22%) had a >15% eGFR decrease after surgery. Nine patients (18%) had WIT longer than 25 minutes. Four patients (8%) had grade ≥2 Clavien-Dindo complications. Twenty-nine (58%) patients had strict Trifecta outcomes. Mean follow-up was 44.2 ± 27.2 months. Tumor recurrence was not observed in any patient. Conclusions: Robot-assisted laparoscopic partial nephrectomy for T1b renal masses can be safely performed in experienced hands. Optimal strict Trifecta outcomes and recurrence rates can be achieved.

Prevention of Urethral Retraction with Stay Sutures (PURS) During Robot-Assisted Radical Prostatectomy Improves Early Urinary Control: A Prospective Cohort Study

OBJECTIVE To evaluate early continence rates with a novel modified vesicourethral anastomosis technique based on prevention of urethral retraction using anastomosis sutures as stay sutures (PURS) during robot-assisted radical prostatectomy. MATERIALS AND METHODS Sixty patients operated by a single surgeon were enrolled and data collected prospectively. This cohort was compared with another consecutive 60 patients operated with standard anastomosis. The new technique is based on preventing urethral retraction of the posterior urethra with two anastomosis sutures being used as stay sutures. The outcomes were prospectively followed and groups compared regarding early continence. International Consultation on Incontinence Questionnaire Short Form was used to assess incontinence and its impact on the quality of life. Pad use (yes or no pads) was evaluated as a more stringent criterion. RESULTS Preoperative patient characteristics were similar between the two groups. Anastomosis was completed faster in PURS group (15.1 vs 18.5 min, p = 0.05). At postoperative week 1 and month 1, the severity and bother of incontinence were significantly less in the PURS group (12.7 vs 4.1 and 10.1 vs 2.6, p < 0.001). PURS cohort reported significantly superior pad-free rates at both postoperative month 1 (73% vs 35%, p < 0.0001) and month 3 (83% vs 53%, p = 0.0004). On multivariable analysis, younger age and the new anastomosis technique were two independent predictors to improve early continence. Four patients in modified anastomosis group (4/60) and 1 in standard anastomosis group (1/60) necessitated temporary urethral recatheterization because of urinary retention. CONCLUSION We describe a simple and time-efficient modified urethrovesical anastomosis technique by using anastomosis sutures as stay sutures to prevent perineal retraction of the urethral stump. Our results demonstrated that the technique is an independent factor impacting early recovery of urinary continence. Future randomized controlled studies would be required to further test the reproducibility of this technique.

Minimizing Ports During Robotic Partial Nephrectomy.

Background and Objective: Robotic upper urinary tract surgery is in most of the cases performed utilizing a standard 5 port configuration. Fewer ports can potentially produce a less invasive operation. Taking in consideration the above we report a novel technique for robot assisted laparoscopic partial nephrectomy utilizing fewer ports and we test its feasibility and safety profile. Methods: Data on 11 robot-assisted laparoscopic partial nephrectomies performed by using our technique from February 2015 through June 2015 were retrospectively analyzed. The robotic platform used was DaVinci Xi (Intuitive Surgical, Inc., Sunnyvale, California, USA) with a 3-arm setup. The AirSeal system (SurgiQuest, Milford, Connecticut, USA) was used as a port allowing simultaneous introduction of 2 instruments for the bedside surgeon, obviating the need for an additional (fourth) robotic arm. A long suction-and-irrigation device and atraumatic grasping forceps were used. Both instruments were introduced through the trocar of the AirSeal system, making simultaneous introduction and use possible. We preferred the long suction-and-irrigation device, because it minimizes collision of the instruments. Results: Mean age and BMI of the patients were 55 ±14.6 y and 29.18 ± 6.85, respectively. Seven tumors were on the right side and 4 were on the left. The mean size of the tumors was 32.45 mm (± 11.31). Surgical time was 132.2 minutes (±37.17), with an estimated blood loss and ischemia time of 103.63 mL (±65.92) and 16.72 minutes (±9.52), respectively. One patient had postoperative bleeding that was resolved without transfusion. The median hospitalization period was 3.9 d (±0.53). Loss of intra-abdominal pressure was not observed, and pressure was stable at 10 mm Hg. Conclusion: The AirSeal System and its valveless trocar eliminated the need for an additional port placement in our series. The technique is feasible, safe, and reproducible; therefore, it may be implemented in selected cases of robot-assisted partial nephrectomies.