R. Thaly

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.

Robotic Equipment Malfunction During Robotic Prostatectomy: A Multi-institutional Study

PURPOSE Robotic-assisted laparoscopic prostatectomy (RALP) is growing in popularity as a treatment option for prostate cancer. As a new technology, little is known regarding the reliability of the da Vinci robotic system. Intraoperative robotic equipment malfunction may force the surgeon to convert the procedure to an open or pure laparoscopic procedure, or possibly even abort the procedure. We report the first large-scale, multi-institutional review of robotic equipment malfunction. MATERIALS AND METHODS A questionnaire was designed to evaluate the rate of perioperative robotic malfunction during RALP. High-volume, experienced surgeons were asked to complete this evaluation based on the analysis of their data. Questions included the overall number of RALPs performed, the number of equipment malfunctions, the number of procedures that had to be converted or aborted, and the part of the robotic system that malfunctioned. RESULTS Eleven institutions participated in the study with a median surgeon volume of 700 cases, accounting for a total case volume of 8240. Critical failure occurred in 34 cases (0.4%) leading to the cancellation of 24 cases prior to the procedure, and the conversion to two laparoscopic and eight open procedures. The most common components of the robot to malfunction were the arms and optical system. CONCLUSIONS Critical robotic equipment malfunction is extremely rare in institutions that perform high volumes of RALPs, with a nonrecoverable malfunction rate of only 0.4%.

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.

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.

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.

Robot-assisted laparoscopic pyeloplasty: minimum 1-year follow-up

Objectives: To evaluate the feasibility and efficacy of robotic-assisted laparoscopic pyeloplasty. Laparoscopic pyeloplasty has been shown to have a success rate comparable to that of the open surgical approach. However, the steep learning curve has hindered its acceptance into mainstream urologic practice. The introduction of robotic assistance provides advantages that have the potential to facilitate precise dissection and intracorporeal suturing. Methods: A total of 50 patients underwent robotic-assisted laparoscopic dismembered pyeloplasty. A four-trocar technique was used. Most patients were discharged home on day 1, with stent removal at 3 weeks. Patency of the ureteropelvic junction was assessed in all patients with mercaptotriglycylglycine Lasix renograms at 1, 3, 6, 9, and 12 months, then every 6 months for 1 year, and then yearly. Results: Each patient underwent a successful procedure without open conversion or transfusion. The average estimated blood loss was 40 ml. The operative time averaged 122 minutes (range 60 to 330) overall. Crossing vessels were present in 30% of the patients and were preserved in all cases. The time for the anastomosis averaged 20 minutes (range 10 to 100). Intraoperatively, no complications occurred. Postoperatively, the average hospital stay was 1.1 days. The stents were removed at an average of 20 days (range 14 to 28) postoperatively. The average follow-up was 11.7 months; at the last follow-up visit, each patient was doing well. Of the 50 patients, 48 underwent one or more renograms, demonstrating stable renal function, improved drainage, and no evidence of recurrent obstruction. Conclusions: Robotic-assisted laparoscopic pyeloplasty is a feasible technique for ureteropelvic junction reconstruction. The procedure provides a minimally invasive alternative with good short-term results.

Radio-frequency ablation of small renal tumors: minimum follow up of 1 year

OBJECTIVE: With the increased utility of complex imaging modalities small renal tumors are being diagnosed with rising frequency. We performed radiofrequency ablation to treat tumors less than 4cm in size using a combination of temperature, impedance, ultrasound and laparoscopic guidance. In this article we reviewed the outcome of radiofrequency ablation of renal tumors at one year at our institution. MATERIALS AND METHODS: Over a three-year period 75 patients with a total of 93 renal tumors underwent radiofrequency ablation. Average patient age was 64.5 years with ASA of 2.9. Indications for nephron sparing were imperative in 33 (solitary kidney 21, renal insufficiency 12). Seventeen patients had significant co-morbidities with ASA score of 3 or more and were thought to be poor candidates for nephrectomy or partial nephrectomy. Five were Jehovahs Witness patients. Average tumor size was 3.2 cm (1.5-4.0). 60% of the tumors were exophytic and 40% deep. Radiofrequency ablation was performed via a transperitoneal approach using the single pronged 3cm Cool tip electrode (Radionics Inc). Tumor was isolated laparoscopically. Prior to ablation the lesions were biopsied. Ablation was performed using both laparoscopic and real-time ultrasound imaging of the boarders of the tumor. During ablation impedance and temperature monitoring was performed. For each tumor two separate ablations were performed at perpendicular angles, the first ablation was for 6 minutes and the second for 3 minutes. The center and periphery of the tumor was monitored to insure that the temperature rose above 70 degrees Celsius. Patients were followed at three-month intervals with triple phase CT scan or MRI to evaluate efficacy of the ablation. Our criteria for recurrent tumor were growth or enhancement of the lesion. RESULTS: Average operative time was 109 minutes with and average EBL of <25cc. Mean hospital stay was 1.4 days. At average follow up of 19.2 months (range 2-24), one lesion showed evidence of tumor recurrence which was corrected surgically. Two masses did show some mild enhancement on CT 6 months post operatively, biopsies showed no evidence of tumor with fibrosis. Of the patients with follow up of greater than 12 months 75% had decreasing size of the lesion, 25% had no change in size. No complications were seen. CONCLUSIONS: Radiofrequency ablation of renal tumors is a feasible alternative for patients that have imperative indication for nephron sparing surgery or those that have significant co-morbidities. The procedure is expedient, efficacious and carries minimal morbidity. It is of extreme importance to follow these patients closely with imaging of the lesion on a frequent basis.

Robot-assisted radical prostatectomy: histopathologic and biochemical recurrence data at one-year follow-up

Introduction: Robotically assisted laparoscopic radical prostatectomy is a minimally invasive alternative for the treatment of prostate cancer. We report the histopathologic and short term PSA outcomes of 500 robotic prostatectomies. Materials and Methods: Five hundred patients underwent robotic radical prostatectomy. The procedure was performed via a six trocar transperitoneal technique. Prostatectomy specimens were analyzed for TNM Stage, Gleasons grade, tumor location, volume, specimen weight, seminal vesicle involvement and margin status. A positive margin was reported if cancer cells were found at the inked specimen margin. PSA data was collected every three months for the first year, then every six months for a year, then yearly. Results: Average pre-operative PSA was 6.9 (1-90) with Gleasons score of 5 (2%), 6 (52%), 7 (40%), 8 (4%), 9(2%). Post operatively histopathologic analysis showed Gleasons 6 (44%), 7(42%), 8(10%), 9(4%). 10%, 5%, 63%, 15%, 5% and 2% had pathologic stage T2a, T2b, T2c, T3a, T3b and T4 respectively. Positive margin rate was 9.4% for the entire series. The positive margin rate per 100 cases was: 13% (1-100), 8% (101-200), 13% (201-300), 5% (301-400) and 8% (401-500). By stage it was 2%, 4%, 2.5% for T2a, T2b, T2c tumors, 23% (T3a), 46% (T3b) and 53% (T4a). For organ confined disease (T2) the margin rate was 2.5% and 31% for non organ confined disease. There were a total of 47 positive margins, 26 (56%) posterolateral, 4 (8.5%) apical, 4 (8.5%) bladder neck, 2 (4%) seminal vesicle and 11 (23%) multifocally. Ninety five percent of patients (n=500) have undetectable PSA (<0.1) at average follow up of 9.7 months. Recurrence has only been seen with non organ confined tumors. Those patients with a minimum follow up of 1 year (average 15.7 months) 95% have undetectable PSA (<.1). Conclusion: Our initial experience with robotic radical prostatectomy is promising. Histopathologic outcomes are acceptable with a low overall margin positive rate. Short term biochemical recurrence free survival has also been good. We believe that the precise dissection allowed by the advantages of laparoscopic robotic surgery will translate into excellent long term oncologic outcomes.

Is the learning curve endless? One surgeon's experience with robotic prostatectomy

Introduction: After performing 1,000 robotic prostatectomies we reflected back on our experience to determine what defined the learning curve and the essential elements that were the keys to surmounting it. Method: We retrospectively assessed our experience to attempt to define the learning curve(s), key elements of the procedure, technical refinements and changes in technology that facilitated our progress. Result: The initial learning curve to achieve basic competence and the ability to smoothly perform the procedure in less than 4 hours with acceptable outcomes was approximately 25 cases. A second learning curve was present between 75-100 cases as we approached more complicated patients. At 200 cases we were comfortably able to complete the procedure routinely in less than 2.5 hours with no specific step of the procedure hindering our progression. At 500 cases we had the introduction of new instrumentation (4th arm, biopolar Maryland, monopolar scissors) that changed our approach to the bladder neck and neurovascular bundle dissection. The most challenging part of the procedure was the bladder neck dissection. Conclusion: There is no single parameter that can be used to assess or define the learning curve. We used a combination of factors to make our subjective definition this included: operative time, smoothness of technical progression during the case along with clinical outcomes. The further our case experience progressed the more we expected of our outcomes, thus we continually modified our technique and hence embarked upon yet a new learning curve.