Richard Sarle

Technique of da vinci robot-assisted anatomic radical prostatectomy

OBJECTIVES Robotic radical prostatectomy is a new procedure for treating prostate cancer. Many centers are attempting this new modality but a detailed description of the technique has not yet been published. We report the technique as performed at the Vattikuti Urology Institute. METHODS At Vattikuti Urology Institute, we have performed more than 30 such operations and have standardized the technique for safe and reproducible treatment of prostate cancer. We collected the patient data and surgical logs to improve and standardize this procedure. We recorded the operation and made relevant modifications after reviewing the recordings to improve the outcome. RESULTS The operation was developed on the scientific foundations of anatomic radical prostatectomy as described by Walsh and the laparoscopic prostatectomy developed at Montsouris. Our technique differs from these procedures because of the need for two surgical teams and the use of fine, endo-wrist instruments with three-dimensional stereoscopic visualization. We describe the patient setup, positioning, port placement, preparation of the robot, docking of the arms, and the surgical steps of performing anatomic prostatectomy with robotic assistance. CONCLUSIONS This report describes the current technique of robotic prostatectomy as developed at the Vattikuti Urology Institute.

An Operative and Anatomic Study to Help in Nerve Sparing during Laparoscopic and Robotic Radical Prostatectomy

OBJECTIVE To provide a detailed description of the steps involved in a laparoscopic radical prostatectomy in relation to the complex neurovascular anatomy of the male pelvis. AIM AND HYPOTHESIS: We aimed at delineating the neurovascular anatomy to assist in nerve preservation during laparoscopic and robotic radical prostatectomies. METHODS A team of urologists and an anatomist performed anatomic dissections of 12 male cadavers using a combination of laparoscopic equipment, magnification, and open surgical dissection. Each step involved in laparoscopic prostatectomy was reviewed in relation to the possible impact the step could have on the neurovascular bundles. RESULTS Dissections were performed systematically to mimic various steps of laparoscopic and robotic prostatectomy. The neurovascular bundles were identified and correlated with video images of actual surgery. This enabled us to construct computer simulations and show the actual nerves on the operative pictures. We specially unraveled the relationship between neurovascular bundles and lateral pelvic and Denonvilliers fascias, both of which enclose and hide these important structures. The course of the bundles was traced from its origin at pelvic plexus to its distal course along the urethra. We also showed the important relationship between pelvic plexus ganglions and seminal vesicles to illustrate the vulnerability of these nerves to thermal, electrical and/or crush injury during seminal vesicle and prostatic pedicle dissections. The importance of additional fine neural plexus along the posterior and antero-lateral surface of the prostate was shown by both gross anatomical and microscopic images. The distal precarious location of the bundles was illustrated by dissections showing anteriorly lifted prostate.These anatomico-operative correlations have not been published for laparoscopic and robotic prostatectomies, which differ significantly in its visual angles, magnifications and sometimes three-dimensional (3D) visualization from its open counter part. CONCLUSION Laparoscopic and robotic radical prostatectomy provides exposure and visualization of male pelvis not previously appreciated. It is only through a careful reexamination of the anatomy of the male pelvis, in the context of this new procedure, that the improvements in visualization and exposure benefit the surgeon. Our work provides a detailed map relating to operative steps to aid the surgeon in the performance of a nerve sparing robotic and laparoscopic radical prostatectomy.

Surgical Robotics and Laparoscopic Training Drills

PURPOSE We investigated the impact of robotics on surgical skills by comparing traditional laparoscopy with the da Vinci Surgical System in the performance of various laparoscopic training drills. SUBJECTS AND METHODS Twenty-one surgeons performed eight timed drills of increasing difficulty with a laparoscopic trainer and the da Vinci Surgical System (Intuitive Surgical Sunnyvale, CA). The mean time to drill completion, drill time variance, and statistical analysis were performed. Surgeons were also questioned about their perception of the robotic technology following completion of the drill series. RESULTS The mean time required to complete the first drill was 69 seconds with laparoscopy and 57 seconds with the robotic system. The mean times for drill two were 67 seconds with laparoscopy and 44 seconds with robotics; for drill three, the times were 88 seconds for laparoscopy and 61 seconds for robotics, and for drill four, 186 seconds with laparoscopy and 71 seconds with robotics. Only the first drill failed to show a statistically significant difference between the laparoscopic and robotic groups. CONCLUSIONS The robotic system allowed surgeons to complete drills faster than traditional laparoscopy. Novice laparoscopic surgeons performed three of the four drills faster robotically than did expert laparoscopic surgeons. These findings may indicate that the attributes of the robotic system level the playing field between surgeons of different skill levels. The next generation of surgeons must focus on this evolving technology and its application in the operating room of the future.

Vattikuti Institute Prostatectomy: a single-team experience of 100 cases.

PURPOSE To analyze the outcomes of the first 100 patients undergoing robotic radical prostatectomy by a single surgical team. PATIENTS AND METHODS From August 2001 to May 2002, we performed robotic radical prostatectomy in 100 patients with localized prostate cancer. The mean age was 60 +/- 0.67 years (SEM), the body mass index 27.5 +/- 0.35, the preoperative prostate specific antigen concentration 7.2 +/- 0.86 ng/mL, and follow-up 5.5 +/- 0.24 months. Thirty-eight patients also underwent pelvic lymph node dissection. We used the da Vinci surgical system and a subperitoneal approach (the Vattikuti Institute Prostatectomy; VIP). This is a prospective outcomes analysis of these patients. RESULTS The mean operating time was 195 +/- 5.0 minutes, and the mean blood loss was 149 +/- 11.8 mL. No patient required blood transfusion. The stages of the cancers were pT(2a) in 21, pT(2b) in 64, pT(3a) in 5, pT(3b) in 9, and pT(3b)N(1) in 1. The positive surgical margin rate was 15%. At 1, 3, and 6 months, the continence rates were 37%, 72%, and 92%, respectively, and the potency rates were 11%, 32%, and 59%. CONCLUSION The VIP is a safe operation with excellent operative parameters, low morbidity, and good surgical margins. The early functional results are promising.

Measuring to Improve: Peer and Crowd-sourced Assessments of Technical Skill with Robot-assisted Radical Prostatectomy

UNLABELLED Because surgical skill may be a key determinant of patient outcomes, there is growing interest in skill assessment. In the Michigan Urological Surgery Improvement Collaborative (MUSIC), we assessed whether peer and crowd-sourced (ie, layperson) video review of robot-assisted radical prostatectomy (RARP) could distinguish technical skill among practicing surgeons. A total of 76 video clips from 12 MUSIC surgeons consisted of one of four parts of RARP and underwent blinded review by MUSIC peer surgeons and prequalified crowd-sourced reviewers. Videos were rated for global skill (Global Evaluation Assessment of Robotic Skills) and procedure-specific skill (Robotic Anastomosis and Competency Evaluation). We fit linear mixed-effects models to estimate mean peer and crowd ratings for each video. Individual video ratings were aggregated to calculate surgeon skill scores. Peers (n=25) completed 351 video ratings over 15 d, whereas crowd-sourced reviewers (n=680) completed 2990 video ratings in 38 h. Surgeon global skill scores ranged from 15.8 to 21.7 (peer) and from 19.2 to 20.9 (crowd). Peer and crowd ratings demonstrated strong correlation for both global (r=0.78) and anastomosis (r=0.74) skills. The two groups consistently agreed on the rank order of lower scoring surgeons, suggesting a potential role for crowd-sourced methodology in the assessment of surgical performance. Lack of patient outcomes is a limitation and forms the basis of future study. PATIENT SUMMARY We demonstrated the large-scale feasibility of assessing the technical skill of robotic surgeons and found that online crowd-sourced reviewers agreed with experts on the rank order of surgeons with the lowest technical skill scores.

Development and Validation of an Objective Scoring Tool for Robot-Assisted Radical Prostatectomy: Prostatectomy Assessment and Competency Evaluation

Purpose: Comprehensive training and skill acquisition by urological surgeons are vital to optimize surgical outcomes and patient safety. We sought to develop and validate PACE (Prostatectomy Assessment and Competence Evaluation), an objective and procedure specific tool to assess the quality of robot‐assisted radical prostatectomy. Materials and Methods: Development and content validation of PACE was performed by deconstructing robot‐assisted radical prostatectomy into 7 key domains utilizing the Delphi methodology. Reliability and construct validation were then assessed using de‐identified videos performed by practicing surgeons and fellows. Consensus for each domain was defined as achieving a content validity index of 0.75 or greater. Reliability was assessed by the intraclass correlation and construct validation using a mixed linear model accounting for multiple ratings on the same video. Results: After 3 rounds consensus was reached on wording, relevance of the skills assessed and concordance between the score assigned and the skill assessed. An intraclass correlation of 0.4 or greater was achieved for all domains. The expert group outperformed trainees in all domains but reached statistical significance in bladder drop (4.5 vs 3.4, p = 0.002), preparation of the prostate (4.4 vs 3.2, p <0.0001), seminal vesicle and posterior plane dissection (8.3 vs 6.8, p = 0.03), and neurovascular bundle preservation (4.1 vs 2.4, p <0.0001). Limitations included the lack of assessment of other key skills such as communication and decision making. Conclusions: PACE is a structured, procedure specific and reliable tool that objectively measures surgical performance during robot‐assisted radical prostatectomy. It can differentiate different levels of expertise and provide structured feedback to customize training and surgical quality improvement.

Iliac artery aneurysm: a fatal cause of urinary retention.

Our institution recently encountered two patients with ruptured iliac artery aneurysms. The first patient died, but as a result of our increased awareness, the second patients aneurysm was diagnosed immediately and operated on successfully. The urologic findings provided subtle clues to this life-threatening condition. We present these two cases with the hope that urologic surgeons will include this condition in their differential diagnosis when evaluating patients with uncharacteristic abdominal pain and urinary symptoms.

Development, validation and clinical application of Pelvic Lymphadenectomy Assessment and Completion Evaluation: intraoperative assessment of lymph node dissection after robot-assisted radical cystectomy for bladder cancer

To develop a scoring tool, Pelvic Lymphadenectomy Appropriateness and Completion Evaluation (PLACE), to assess the intraoperative completeness and appropriateness of pelvic lymph node dissection (PLND) following robot‐assisted radical cystectomy (RARC).

Training: Preparing the Robotics Team for Their First Case

Robotic prostatectomy is hard to learn but easy to do. Good judgment comes from experience and experience comes from bad judgment. Many surgeons have heard this aphorism and understand its truth. It is self-evident that adequate training can and should take the place of the bad judgment that comes from inexperience. What constitutes an adequate training experience will depend on many factors and is likely to vary from institution to institution. In this chapter, we will discuss our philosophy of and experience with training in robotic surgery at the Vattikuti Urology Institute (VUI). This has developed and evolved over the almost 2400 robotic-assisted procedures, including radical prostatectomy, radical cystectomy, radical and partial nephrectomy, performed by our surgical teams.

Radical Cystectomy and Urinary Diversion

Radical cystectomy with pelvic lymph node dissection represents the standard of care for muscle-invasive and refractory nonmuscle-invasive bladder cancer. Growing interest in minimally invasive approaches, especially robot-assisted radical cystectomy, has been spurred aiming to decrease perioperative morbidity. However, irrespective of the surgical approach, radical cystectomy remains a morbid procedure with significant complications, mostly are diversion-related. Such complications vary according to the type (ileal conduit vs continent diversion) and technique of diversion (intracorporeal vs extracorporeal). They may respond to conservative, endoscopic, and percutaneous measures, but many will require reoperations during convalescence or even years later. There has been paucity of data on management of complications and their outcomes, especially those requiring surgical intervention. In this chapter, we describe postoperative complications related to radical cystectomy and urinary diversion that may require reoperations, their causes, means of prevention, and treatment including operative management.