Richard E. Link

A Prospective Comparison of Robotic and Laparoscopic Pyeloplasty

Objective:To determine whether robotic-assisted pyeloplasty (RLP) has any significant clinical or cost advantages over laparoscopic pyeloplasty (LP) for surgeons already facile with intracorporeal suturing. Summary Background Data:LP has become an established management approach for primary ureteropelvic junction obstruction. More recently, the da Vinci robot has been applied to this procedure (RLP) in an attempt to shorten the learning curve. Whether RLP provides any significant advantage over LP for the experienced laparoscopist remains unclear. Methods:Ten consecutive cases each of transperitoneal RLP and LP performed by a single surgeon were compared prospectively with respect to surgical times and perioperative outcomes. Cost assessment was performed by sensitivity analysis using a mathematical cost model incorporating operative time, anesthesia fees, consumables, and capital equipment depreciation. Results:The RLP and LP groups had statistically indistinguishable demographics, pathology, and similar perioperative outcomes. Mean operative and total room time for RLP was significantly longer than LP by 19.5 and 39.0 minutes, respectively. RLP was much more costly than LP (2.7 times), due to longer operative time, increased consumables costs, and depreciation of the costly da Vinci system. However, even if depreciation was eliminated, RLP was still 1.7 times as costly as LP. One-way sensitivity analysis showed that LP operative time must increase to almost 6.5 hours for it to become cost equivalent to RLP. Conclusions:For the experienced laparoscopist, application of the da Vinci robot resulted in no significant clinical advantage and added substantial cost to transperitoneal laparoscopic dismembered pyeloplasty.

Telesurgery: Remote Monitoring and Assistance During Laparoscopy

In comparison to open surgery, laparoscopy results in less postoperative pain, shorter hospitalization, more rapid return to the work force, a better cosmetic result, and a lower incidence of postoperative intra-abdominal adhesions. These advantages are indisputable when comparing large series for cholecystectomy and smaller series for pelvic lymph node dissection, nephrectomy, and bladder neck suspension in experienced hands. Urologists have an obligation to explore the application of these methods to urologic disease and to adjust the standard of care accordingly. Several barriers to the expansion of urologic laparoscopic surgery exist. The experience in extirpative and reconstructive urologic procedures is limited when compared with the data on cholecystectomy. These procedures are technically complex and demand advanced laparoscopic skills and familiarity with laparoscopic anatomy. The steep learning curve translates into long operative times and an unacceptably high rate of complications for inexperienced laparoscopic surgeons. Most practicing urologists have no formal training in advanced laparoscopy, and no formal credentialing guidelines exist. Telesurgical technology may provide one solution to this problem. Through telesurgical mentoring, less experienced surgeons with basic laparoscopic skills could receive training in advanced techniques from a world expert without the need for travel. These systems could also be used to proctor laparoscopic cases for credentialing purposes and to provide a more uniform standard of care. This review has outlined some of the exciting progress made in the field of telesurgery over the past 10 years and described some of the technical and legal obstacles that remain to be surmounted. During the 1990s, urologists were at the forefront of innovation in remote telepresence surgery. As the scope of minimally invasive urologic surgery expands during the first few decades of the twenty-first century, telesurgical mentoring should have an increasingly important role.

Indications for pelvic lymphadenectomy in prostate cancer

Clearly, pelvic lymphadenectomy can provide important staging information in the management of prostate cancer, but this benefit is counterbalanced by a modest increase in morbidity and the significant cost of the procedure. It is difficult to provide universal recommendations concerning the indications for pelvic lymphadenectomy. Part of the problem lies in the fact that urologists perform pelvic lymphadenectomy for several different reasons. Some surgeons perform pelvic lymphadenectomy to better counsel patients after radical prostatectomy about their risk for disease progression and for planning adjuvant radiotherapy or hormonal therapy. For these surgeons, preoperative clinical staging parameters do not exclude patients from pelvic lymphadenectomy, and frozen section analysis intraoperatively provides no useful information. Alternatively, the staging information from pelvic lymphadenectomy can be used to justify cancellation of the subsequent prostatectomy should regional spread of prostate cancer be identified, sparing the patient the morbidity of an unnecessary radical prostatectomy. With this approach, despite the false-negative rate of up to 30%, the expense of frozen section analysis seems justified. For this second group of surgeons, the problem becomes balancing the modest morbidity and cost of pelvic lymphadenectomy against the probability that nodal spread of prostate cancer will be missed if the procedure is omitted. The authors consider a greater than 4% risk for missing regional disease to be unacceptable in this setting. Following this assumption, Table 3 outlines parameters for clinical stage, Gleason score, and preoperative PSA within which pelvic lymphadenectomy is indicated. These recommendations are based on [table: see text] predictions from the Partin nomogram, which has been validated using a series of over 4000 patients. For the large number of patients with clinical T1c disease and a preoperative PSA less than 10 ng/mL, bilateral pelvic lymphadenectomy is indicated only if prostate biopsy identifies tumor of Gleason grade 4 or higher. For lower-grade tumors in this patient population, the risk for nodal metastasis was less than 5% in the Johns Hopkins and Mayo Clinic series of over 5800 patients with prostate cancer. For a large pool of patients, the several thousand dollar cost of pelvic lymphadenectomy and the risk for injury to the obturator nerves and vessels, the formation of lymphoceles, and chronic genital edema can be eliminated with low risk. A nomogram-based approach provides only a starting point for a decision analysis framework to determine whether the surgeon should perform lymphadenectomy at the time of radical prostatectomy because current nomograms predict only lymph node positivity. In a decision analysis framework, some patient and physician value is derived from a negative lymphadenectomy. Moreover, the morbidity associated with pelvic lymphadenectomy and the potential inconvenience associated with treating such morbidity also would be factored into the decision. Consequently, a decision analysis framework that takes into account prognostic value, costs, morbidity, and health state uses ultimately will provide the most informative method for determining when pelvic lymphadenectomy is indicated in patients with prostate cancer.

Differences in Ablation Size in Porcine Kidney, Liver, and Lung After Cryoablation Using the Same Ablation Protocol

OBJECTIVE The purpose of our study was to assess the variation in size of acute necrosis and the variation in thermal map measured during cryoablation in multiple organs using the same ablation protocol for each organ. MATERIAL AND METHODS Eight female pigs underwent one cryoablation per organ of kidney, lung, and liver performed with open surgery with a 2.4-mm cryoprobe. A 12- and 8-minute double-freeze cycle was used. Intratissue temperatures were monitored using 16-gauge thermometers spaced at 5.0-mm increments from the cryoprobe. The comparison of results among tissues was performed using the multiple analysis of variance. The -20 degrees C thermal diameter was correlated with tissue damage. The kidneys, lungs, and liver were removed and examined histologically for a pathologic complete coagulative necrosis zone. RESULT A single 2.4-mm cryoprobe had a mean ice ball diameter in kidney, lung, and liver of 38.5 +/- 4.7, 35.5 +/- 3.6, and 32.5 +/- 2.7 mm, respectively. A mean -20 degrees C thermal diameter was achieved at 24.07 +/- 1.38 mm in kidney, 12.76 +/- 3.0 mm in lung, and 8.8 +/- 3.7 mm in liver by means of regression analysis. The acute pathologic complete coagulative necrosis zone size was 21.0 +/- 1.56 mm (kidney), 11.6 +/- 1.48 mm (lung), and 8.0 +/- 1.20 mm (liver). CONCLUSION The inherent characteristics of different organs manifest different ablation zone sizes during cryoablation despite the same ablation protocol being used. This information should be factored into planning for ablation procedures.

Which skills really matter? proving face, content, and construct validity for a commercial robotic simulator

BackgroundA novel computer simulator is now commercially available for robotic surgery using the da Vinci® System (Intuitive Surgical, Sunnyvale, CA). Initial investigations into its utility have been limited due to a lack of understanding of which of the many provided skills modules and metrics are useful for evaluation. In addition, construct validity testing has been done using medical students as a “novice” group—a clinically irrelevant cohort given the complexity of robotic surgery. This study systematically evaluated the simulator’s skills tasks and metrics and established face, content, and construct validity using a relevant novice group.MethodsExpert surgeons deconstructed the task of performing robotic surgery into eight separate skills. The content of the 33 modules provided by the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA) was then evaluated for these deconstructed skills and 8 of the 33 determined to be unique. These eight tasks were used for evaluating the performance of 46 surgeons and trainees on the simulator (25 novices, 8 intermediate, and 13 experts). Novice surgeons were general surgery and urology residents or practicing surgeons with clinical experience in open and laparoscopic surgery but limited exposure to robotics. Performance was measured using 85 metrics across all eight tasks.ResultsFace and content validity were confirmed using global rating scales. Of the 85 metrics provided by the simulator, 11 were found to be unique, and these were used for further analysis. Experts performed significantly better than novices in all eight tasks and for nearly every metric. Intermediates were inconsistently better than novices, with only four tasks showing a significant difference in performance. Intermediate and expert performance did not differ significantly.ConclusionThis study systematically determined the important modules and metrics on the da Vinci Skills Simulator and used them to demonstrate face, content, and construct validity with clinically relevant novice, intermediate, and expert groups. These data will be used to develop proficiency-based training programs on the simulator and to investigate predictive validity.

Association of Surgeon Subjective Characterization of Nerve Sparing Quality With Potency Following Laparoscopic Radical Prostatectomy

PURPOSE We assessed whether a surgeon self-graded assessment of neurovascular bundle preservation quality predicted potency following laparoscopic radical prostatectomy. MATERIALS AND METHODS From April 2001 to January 2007 a total of 767 laparoscopic radical prostatectomies were performed by 2 surgeons who graded left and right neurovascular bundle sparing qualities on a scale of 0 to 5. The total number of nerves spared was also recorded. We defined a composite variable, the bilateral sum neurovascular bundle sparing score, to encode 1 independent variable (scale of 0 to 10) for analysis. Multivariate linear regression models were evaluated to assess the significance of the bilateral sum neurovascular bundle sparing score for predicting validated potency outcomes, controlling for significant clinical variables in preoperatively potent men (Sexual Health Inventory for Men 21 or greater). The bilateral sum neurovascular bundle sparing score based model was compared to a model based on the separate number of nerves spared. RESULTS A total of 313 patients were preoperatively potent, of whom 226 (72%), 77 (25%) and 10 (3%) underwent bilateral, unilateral and no neurovascular bundle sparing, respectively. Of the men who underwent bilateral neurovascular bundle sparing 64.3% were engaging in intercourse by 1 year. Regression models indicated that the bilateral sum neurovascular bundle sparing score and the number of nerves spared were highly significant independent positive predictors of postoperative sexual function (p <0.001). The bilateral sum neurovascular bundle sparing score model provided differential prognostic information in the majority group that underwent bilateral nerve preservation. Other independently predictive variables were patient age at surgery, months since surgery and preoperative Sexual Health Inventory for Men 21 to 25 (each p <0.001). CONCLUSIONS Cavernous nerve preservation during laparoscopic radical prostatectomy is not an all or none phenomenon. A surgeon subjective sense of neurovascular bundle sparing quality may aid in accurately characterizing the return of sexual function following laparoscopic radical prostatectomy. Partial nerve preservation may lead to an incremental improvement in the return of sexual function.

Laparoscopic radical prostatectomy.

Abstract Laparoscopic radical retropubic prostatectomy (LRRP) is a new technique for treating organ-confined prostate carcinoma. The procedure was first described and proven to be feasible in 1997. To date, the results from over 150 cases have been reported in the literature. LRRP appears to be an efficacious procedure and deserves careful consideration. However, open radical retropubic prostatectomy (RRP) is routinely performed with excellent results and minimal morbidity. Whether LRRP offers any compelling benefit over open RRP remains to be determined, and will require a systematic comparison of technical advantages, morbidity, and long-term functional outcomes.

The Female Factor: Predicting Compliance with a Post-Prostatectomy Erectile Preservation Program

INTRODUCTION Early post-radical prostatectomy (RP) erectile preservation (EP) therapy may be critical to preserve erections after surgery. AIM To assess if pre-RP female sexual function predicts of partner compliance with an EP protocol. MAIN OUTCOME MEASURES Compliance, defined as use of localized penile EP therapy (intracavernosal injections [ICIs], vacuum erection device [VED], or alprostadil) at 3 and 6 months after RP. METHODS Records of patients enrolled in our EP program from April 2007 to June 2008 were reviewed. Before surgery, patients completed the Sexual Health Inventory for Men (SHIM) and their female partners completed the Female Sexual Function Index (FSFI) questionnaire. Prior to surgery, patients were advised to take sildenafil 25 mg every nightly and use a 250-µg alprostadil suppository three times/week. At 1 month, additional daily use of a VED was encouraged. All patients unable to achieve erections sufficient for penetration were encouraged to initiate ICI of Trimix (phentolamine, papaverine, and PGE1) twice weekly after 3 months following surgery. Data were analyzed using binary logistic regression analysis holding all input variables constant. RESULTS Twenty-nine patients had preoperative SHIM>7 and pre-RP partner FSFI data available. After a 4-week follow-up, compliance with alprostadil suppository declined and both ICI and VED usage increased. At 6 months, six (25.0%) patients had return of natural erectile function and 22 (91.7%) were achieving assisted erections. Higher preoperative partner FSFI scores were associated with greater compliance to the localized penile therapy component of our EP protocol (risk ratio 3.8, P=0.05). CONCLUSIONS Preoperative female sexual function correlated with greater partner compliance with the localized component of our EP protocol. Consideration of a female partners preoperative sexual function in predicting patient erectile function recovery after RP is warranted. Future studies are necessary to determine the clinical significance of this factor.

Comparison of laparoendoscopic single site (LESS) and conventional laparoscopic donor nephrectomy at a single institution

Most transplant centres harvest living donor kidneys via a conventional laparoscopic surgical approach. Laparoendoscopic single‐site donor nephrectomy (LESS‐DN) is a relatively novel minimally invasive approach that allows the surgery to be performed via a single incision. This technique may be advantageous in decreasing surgical morbidity and improving cosmetic outcomes, thus plausibly reducing the barriers to kidney donation. The study demonstrates the safety and feasibility of LESS‐DN in a large consecutive series of kidney donors. Comparative analysis between LDN and LESS‐DN showed that there was a significant decrease in intra‐operative blood loss and allograft warm ischaemia time in the LESS‐DN group, but also a significant increase in operating time. Other peri‐operative outcomes were similar between the two approaches. Evaluation of the LESS‐DN cases alone revealed that, the operating times did not significantly change through the course of the series. Using this outcome as a surrogate for technical difficulty suggests a relatively shallow learning curve for LESS‐DN.

The Impact of Prostate Size on Urinary Quality of Life Indexes Following Laparoscopic Radical Prostatectomy

PURPOSE We assessed the effects of prostate size on long-term health related quality of life and functional outcomes after laparoscopic radical prostatectomy. MATERIALS AND METHODS A total of 729 consecutive patients who underwent laparoscopic radical prostatectomy for localized prostate cancer were stratified by pathological prostate gland weight, including group 1--less than 35 gm, group 2--35 to 70 gm and group 3--greater than 70 gm. Urinary health related quality of life was assessed preoperatively and at regular intervals following laparoscopic radical prostatectomy using the validated Expanded Prostate Cancer Index Composite questionnaire. RESULTS A total of 613 evaluable patients were studied with a mean age of 57.7 years, a preoperative prostate specific antigen of 6.0 ng/ml, a median preoperative and postoperative Gleason score of 6, and a mean pathological gland weight of 51.3 gm (range 13.4 to 145.7). Patients with the largest glands had significantly worse baseline urinary function, as demonstrated by Expanded Prostate Cancer Index Composite urinary domain summary (p <0.001) and subscale scores, including scores for urinary bother (p <0.001), urinary irritative/obstructive (p = 0.001) and urinary incontinence (p = 0.03). Patients in group 3 also had significantly older age, a higher body mass index, longer operative time and more blood loss (each p <0.05). Despite preoperative differences and possible confounders all groups approached similar urinary health related quality of life outcomes at all time points postoperatively. At 12 months patients with the largest glands had improved Expanded Prostate Cancer Index Composite urinary irritative/obstructive and urinary bother subscale scores compared to their baseline scores (p <0.05). CONCLUSIONS In laparoscopic radical prostatectomy despite preoperative differences increasing prostatic size is not associated with delayed or worse postoperative urinary health related quality of life. Furthermore, in patients with large glands an improvement in urinary irritative/obstructive and bother symptoms from baseline may be seen 12 months postoperatively.