Rakeeba Din

The First 100 Consecutive, Robot-assisted, Intracorporeal Ileal Conduits: Evolution of Technique and 90-day Outcomes

BACKGROUND Robot-assisted radical cystectomy (RARC) has evolved over the last few years to become an acceptable alternative option to open radical cystectomy. Most series of RARC used an open approach to urinary diversion. Even though robot-assisted intracorporeal urinary diversion (RICUD) is the natural extension of RARC, few centers have reported their experiences with RICUD in general, and in particular, of robot-assisted intracorporeal ileal conduits (RICIC). OBJECTIVE To report our experience with RICIC using the Marionette technique. DESIGN, SETTING, AND PARTICIPANTS The first 100 consecutive patients who underwent RARC and RICIC, and had ≥ 3 mo of postoperative follow-up were included in this study. Patients were divided into four groups of 25 patients each to study the evolution of our surgical technique. INTERVENTION RICIC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Intraoperative, pathologic, and 90-d postoperative outcomes for the four groups and the overall cohort were compared using the Fisher exact test (categorical variables) and the Kruskal-Wallis test (continuous variables). Continuous variables were reported as median (range) and categorical variables were specified as frequency (percentage). RESULTS AND LIMITATIONS Overall operative and specific diversion times were 352 and 123 min, respectively. Estimated blood loss was 300 ml, lymph node yield was 24, and positive surgical margin rate was 4%. Length of hospital stay increased from 7 d for group 1 to 9 d for group 4. The overall 90-d complication rate was 81%; 19% of complications were high grade. Infections were the most common complications, representing 31% of all complications. There were no statistically significant intergroup differences except in diversion time, intraoperative transfusions, and length of stay. CONCLUSIONS RICIC diversion is safe, feasible, and reproducible. Larger series with longer follow-up are needed to validate the procedure and define its place in the minimally invasive urologic armamentarium. Quality of life studies need to be conducted to compare benefits of intracorporeal urinary diversion.

Understanding Avoidance, Refusal, and Abandonment of Chemotherapy Before and After Cystectomy for Bladder Cancer

OBJECTIVE To analyze trends in perioperative chemotherapy and optimize use of neoadjuvant chemotherapy for bladder cancer. METHODS From 2005-2012, 284 consecutive patients underwent robot-assisted radical cystectomy at our facility. Patients with disease ≥ T2 and nodal involvement and positive surgical margins were reviewed and considered candidates for referral to medical oncology for chemotherapy. The study was conducted in two phases: phase 1 included 242 consecutive patients between 2005 and 2011, and phase 2 analyzed the effect of changes in 42 patients during a 1-year period (2011-2012). RESULTS In phase 1, 148 patients (61%) were candidates for neoadjuvant chemotherapy (NAC). Consultation for NAC was sought for 44 patients (29%), and 104 (71%) did not receive consultation. Of the 44 patients, 36% received NAC, 7% refused, 32% were recommended for immediate cystectomy, and 25% did not receive NAC for other reasons. Phase 2 was more stringent, with a multidisciplinary approach. Significant improvement in referral and NAC use was seen. About 78% vs 30% of patients were seen by medical oncology for consideration of NAC before robot-assisted radical cystectomy and 71% vs 36% received NAC compared with phase 1. The NAC utilization rate improved from 10.8% to 55% over 1 year with a diligent multidisciplinary approach. Medical comorbidities were the main reason for patients not receiving adjuvant chemotherapy (AC; 30% and 33%). CONCLUSION A multidisciplinary approach and coordination of services can help optimize the use of neoadjuvant chemotherapy for bladder cancer.

Simulation-based robot-assisted surgical training: A health economic evaluation

OBJECTIVE To determine the overall cost effectiveness of surgical skills training on Robotic Surgical Simulator (RoSS). METHODS This study evaluates the cost analysis of utilizing RoSS for robot-assisted surgical training, at Roswell Park Center for Robotic Surgery. Trainees were queried for time spent on the RoSS console over a period of 1 year, starting from June 2010 to June 2011. Time spent was converted to training time consumed on robotic console, resulting in loss of OR time and revenue. The mechanical durability of the RoSS was also determined. RESULTS 105 trainees spent 361 h on the RoSS. This duration converted to 73 robot-assisted radical prostatectomy cases, and 72 animal lab sessions. RoSS prevented a potential loss of

External validation of preoperative and postoperative nomograms for prediction of cancer-specific survival, overall survival and recurrence after robot-assisted radical cystectomy for urothelial carcinoma of the bladder

600,000, while 72 animal labs would have cost more than

Health-related quality of life outcomes after robot-assisted and open radical cystectomy using a validated bladder-specific instrument: A multi-institutional study

72,000 without including initial robot installation, annual maintenance and personnel expenses. The mechanical durability testing determined breakdown at 180 and 360 h for master control and pinch device, which were repaired under warranty. CONCLUSION RoSS is a cost effective surgical simulator for implementation of a simulation-based robot-assisted surgical training program.

Readmission after robot-assisted radical cystectomy: outcomes and predictors at 90-day follow-up.

To externally validate currently available bladder cancer nomograms for prediction of all‐cause survival (ACS), cancer‐specific survival (CSS), other‐cause mortality (OCM) and progression‐free survival (PFS).