Peter Rimington

Robotic-assisted Laparoscopic Radical Cystectomy with Extracorporeal Urinary Diversion: Initial Experience

BACKGROUND The use of robotic technology for laparoscopic prostatectomy is now well established. The same cannot yet be said of robotic-assisted laparoscopic radical cystectomy (RARC), which is performed in just a few centres worldwide. OBJECTIVE We present our technique and experience of this procedure using the da Vinci surgical system. DESIGN, SETTING, AND PARTICIPANTS From 2004 to 2007, 23 patients underwent RARC and urinary diversion at our institution. SURGICAL PROCEDURE We report the development of our technique for RARC, which involves posterior dissection, lateral pedicle control, anterior dissection, and lymphadenectomy prior to either ileal conduit urinary diversion or Studer pouch reconstruction performed extracorporeally. MEASUREMENTS Demographic and perioperative data were recorded prospectively. Oncologic and functional outcomes were assessed at 3- to 6-mo intervals. RESULTS AND LIMITATIONS To date, 23 patients have undergone this procedure at our institution. Of those, 19 had ileal loop urinary diversion and 4 were suitable for Studer pouch reconstruction. Mean total operative time plus or minus (+/-) standard deviation (SD) was 397+/-83.8min. Mean blood loss +/-SD was 278+/-229ml with one patient requiring a blood transfusion. Surgical margins were clear in all patients with a median +/-SD of 16+/-8.9 lymph nodes retrieved. The complication rate was 26%. At a mean follow-up +/-SD of 17+/-13 (range 4-40) mo, one patient had died of metastatic disease and one other is alive with metastases. The remaining 21 patients are alive without recurrence. CONCLUSIONS RARC remains a procedure in evolution in the small number of centres carrying out this type of surgery. Our initial experience confirms that it is feasible with acceptable morbidity and good short-term oncologic results.

The Learning Curve of Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

BACKGROUND Robot-assisted radical cystectomy (RARC) has evolved as a minimally invasive alternative to open radical cystectomy for patients with invasive bladder cancer. OBJECTIVE We sought to define the learning curve for RARC by evaluating results from a multicenter, contemporary, consecutive series of patients who underwent this procedure. DESIGN, SETTING, AND PARTICIPANTS Utilizing the International Robotic Cystectomy Consortium database, a prospectively maintained and institutional review board-approved database, we identified 496 patients who underwent RARC by 21 surgeons at 14 institutions from 2003 to 2009. MEASUREMENTS Cut-off points for operative time, lymph node yield (LNY), estimated blood loss (EBL), and margin positivity were identified. Using specifically designed statistical mixed models, we were able to inversely predict the number of patients required for an institution to reach the predetermined cut-off points. RESULTS AND LIMITATIONS Mean operative time was 386 min, mean EBL was 408 ml, and mean LNY was 18. Overall, 34 of 482 patients (7%) had a positive surgical margin (PSM). Using statistical models, it was estimated that 21 patients were required for operative time to reach 6.5h and 8, 20, and 30 patients were required to reach an LNY of 12, 16, and 20, respectively. For all patients, PSM rates of <5% were achieved after 30 patients. For patients with pathologic stage higher than T2, PSM rates of <15% were achieved after 24 patients. CONCLUSIONS RARC is a challenging procedure but is a technique that is reproducible throughout multiple centers. This report helps to define the learning curve for RARC and demonstrates an acceptable level of proficiency by the 30th case for proxy measures of RARC quality.

Robotic assisted radical cystectomy: short to medium-term oncologic and functional outcomes.

Purpose:  To report short‐ and medium‐term oncological and functional outcomes of the first robotic‐assisted laparoscopic radical cystectomy (RARC) series from the UK.

Single-port ‘scarless’ laparoscopic nephrectomies: the United Kingdom experience

To present the UK experience to date with laparoendoscopic single‐site surgery (LESS) simple nephrectomy.

Initial experience with the EndoAssist camera-holding robot in laparoscopic urological surgery

Although the advantages of laparoscopic surgery are well documented, one disadvantage is that, for optimum performance, an experienced camera driver is required who can provide the necessary views for the operating surgeon. In this paper we describe our experience with urological laparoscopic techniques using the novel EndoAssist robotic camera holder and review the current status of alternative devices. A total of 51 urological procedures (25 using the EndoAssist device and 26 using a conventional human camera driver) conducted by three experienced surgeons were studied prospectively, including nephrectomy (simple and radical), pyeloplasty, radical prostatectomy, and radical cystoprostatectomy. The surgeon noted the extent of body comfort and muscle fatigue in each case. Other aspects documented were ease of scope movement, i.e. usability, need to clean the telescope, time of set-up, surgical performance, and whether it was necessary to change the position of the arm during the surgery. All three surgeons involved in the evaluation felt comfortable throughout all procedures, with no loss of autonomy. It was, however, obvious that the large arc generated whilst doing a nephrectomy led to more episodes of lens cleaning, and the arm had to be relocated on some occasions. Clearer benefits were seen while performing pelvic surgery or pyeloplasty, perhaps because the arc of movement was smaller. The EndoAssist is an effective, easy to use device for robotic camera driving which reduces the constraint of having to have an experienced camera driver for optimum visualisation during laparoscopic urological procedures.

Minimally invasive radical cystectomy

Radical cystectomy (RC) has been the standard surgical treatment for muscleinvasive, organ-confined bladder cancer. Other indications for RC include high-risk superficial bladder tumours resistant to intravesical therapy, carcinoma in situ resistant to intravesical immunoor chemotherapy, and recurrent multifocal superficial disease refractory to repeat transurethral resection with/without intravesical therapy. At present, RC has better local disease control and 5-year survival than the other treatment options. RC is now often combined with cycles of neoadjuvant chemotherapy. RC by the well established open method has a significant complication rate approaching 25%, including mortality, even in the best hands. The median blood loss is often 1500–1800 mL and many patients subsequently require a blood transfusion. The hospital stay and full recovery are consequently prolonged, with 19–21 days quoted as the standard UK average. As experience with laparoscopy and robotics continues to grow, minimally invasive (MI)RC is emerging as a real alternative to traditional open cystectomy. We conducted a Medline search of all reported series of ‘laparoscopic/ robotic cystectomy’ and large series of ‘open radical cystectomy (ORC).

ROBOTICALLY ASSISTED RADICAL CYSTECTOMY

Our technique, derived from open (ORC) and laparoscopic RC (LRC) has developed over 4 years [1] and involves posterior dissection between the rectum and prostate, followed by control of the lateral pedicles to the bladder and finally anterior dissection and pelvic lymphadenectomy. We initially used clips to control the lateral pedicles, but subsequently switched to a linear stapler as the blood loss was somewhat higher with clips. Currently a harmonic scalpel seems to be the most efficient and cost-effective method. In women the vagina is reconstructed with a running intracorporeal suture. Although the advent of robotics has renewed interest in completely intracorporeal reconstruction, we have preferred to perform this extracorporeally either through an appendix incision or a small midline incision in patients with body mass index of > 30 kg/m 2 . In 30 patients the operative duration was 5.5–8 h, depending on whether an ileal conduit or Stüder pouch was created, the estimated blood loss ≈ 200 mL and the hospital stay either 1 week for the conduits or 2 weeks for the pouches.

Evaluation of a commercial vascular clip: risk factors and predictors of failure from in vitro studies.

To assess risk factors and predictors of failure of the Hem‐o‐lokTM vascular clip (Weck Closure Systems, Research Triangle Park, NC, USA) using vessels harvested from a porcine model.

Laparoscopic Extirpative Renal Surgery in the Octogenarian Population

PURPOSE Laparoscopic extirpative surgery for cancer is usually safe and effective, even in the elderly. However, the risk to benefit ratio of laparoscopic nephrectomies in patients aged over 80 has not been quantified objectively. The purpose of this study is to analyze the outcomes of this technique in the octogenarian population. MATERIALS AND METHODS Between July 2001 and March 2008, 37 laparoscopic nephrectomies were performed for malignancy in patients over the age of 80. Patient demographics and perioperative and postoperative data were analyzed retrospectively. RESULTS Population characteristics include a median age of 82, 65% female with a median American Society of Anesthesiologists score of 2. In all, 57% of the laparoscopic nephrectomies were left sided. Twenty-four laparoscopic nephrectomies were for renal cell carcinoma, with 13 nephroureterectomies for transitional cell carcinoma. A total of 32% had postoperative complications, three of which resulted in death. Average total length of hospital stay was 10.5 days. Stage of malignancy varied from pT(a) to pT(4), and the mean size of the specimen was 169 x 77 mm with a mean tumor size of 54 x 44 mm. At 1 year follow-up (n = 27), 85% were alive, and at 3 years (n = 21) 52% were alive and free of disease. CONCLUSION Our small study suggests that laparoscopic nephrectomy in this age group is feasible, although the results are far from ideal. Cancer-specific survival rates are poor in this population, and therefore the risk to benefit ratio should be weighed up carefully prior to committing a patient in this age group to extirpative surgery.

The Eastbourne extraction: forceps removal of large laparoscopic nephrectomy specimens without morcellation.

Intact specimen retrieval after laparoscopic nephrectomy for renal tumors is considered the gold standard. Removal of large specimens can be a challenge. A technique to aid large bagged specimen removal using Wrigleys obstetric forceps is described.