Ronald S. Boris

Maximizing Console Surgeon Independence during Robot-Assisted Renal Surgery by Using the Fourth Arm and TilePro™

PURPOSE We describe multiple uses of the fourth robotic arm and TilePro on the da Vinci S surgical system to maximize console surgeon independence from the assistant during robot-assisted renal surgery. MATERIALS AND METHODS We prospectively evaluated the use of the fourth robotic arm and TilePro on the da Vinci S during robot-assisted radical nephrectomy (RRN) and robot-assisted partial nephrectomy (RPN). The fourth robotic arm was used to provide kidney retraction, place the renal hilum on stretch, control vascular structures, apply and remove bulldog clamps during partial nephrectomy, and secure renal capsular stitches. TilePro was used to project intraoperative ultrasonography and preoperative CT images onto the console screen. RESULTS From January 2006 to June 2008, 90 robot-assisted kidney procedures were performed, of which the fourth robotic arm was used in 46 cases (RRN, 18; RPN, 24; nephroureterectomy, 4). The fourth robotic arm facilitated consistent kidney retraction for dissection of the renal hilum and mobilization of the kidney. The robotic Hem-o-Lok clip applier effectively controlled renal hilar vessels during eight RPN cases and secured renal capsular stitches during two RPN cases. Bulldog clamps were successfully applied to the renal artery during RPN using the fourth arm in two cases. TilePro was used during 22 RPN cases to project intraoperative ultrasonographic images and preoperative CT images onto the console screen as a picture-on-picture image to guide tumor resection. CONCLUSIONS Robotic instruments used with the fourth robotic arm may give the console surgeon greater independence from the assistant during robot-assisted kidney surgery by facilitating steps such as kidney retraction, hilar dissection, and vascular control. The TilePro feature of the da Vinci S can be used to project intraoperative ultrasonography and preoperative imaging onto the console screen, potentially guiding tumor localization and resection during RPN without the need to leave the console to view external images.

Robot-assisted laparoscopic partial nephrectomy for tumors greater than 4 cm and high nephrometry score: feasibility, renal functional, and oncological outcomes with minimum 1 year follow-up.

OBJECTIVES Minimally invasive robotic assistance is being increasingly utilized to treat larger complex renal masses. We report on the technical feasibility and renal functional and oncologic outcomes with minimum 1 year follow-up of robot-assisted laparoscopic partial nephrectomy (RALPN) for tumors greater than 4 cm. MATERIALS AND METHODS The urologic oncology database was queried to identify patients treated with RALPN for tumors greater than 4 cm and a minimum follow-up of 12 months. We identified 19 RALPN on 17 patients treated between June 2007 and July 2009. Two patients underwent staged bilateral RALPN. Demographic, operative, and pathologic data were collected. Renal function was assessed by serum creatinine levels, estimated glomerular filtration rate, and nuclear renal scans assessed at baseline, 3, and 12 months postoperatively. All tumors were assigned R.E.N.A.L. nephrometry scores (http://www.nephrometry.com). RESULTS The median nephrometry score for the largest tumor from each kidney was 9 (range 6-11) while the median size was 5 cm (range 4.1-15). Three of 19 cases (16%) required intraoperative conversion to open partial nephrectomy. No renal units were lost. There were no statistically significant differences between preoperative and postoperative creatinine and eGFR. A statistically significant decline of ipsilateral renal scan function (49% vs. 46.5%, P = 0.006) was observed at 3 months and at 12 mo postoperatively (49% vs. 45.5%, P = 0.014). None of the patients had evidence of recurrence or metastatic disease at a median follow-up of 22 months (range 12-36). CONCLUSIONS RALPN is feasible for renal tumors greater than 4 cm with moderate or high nephrometry scores. Although there was a modest decline in renal function of the operated unit, RALPN may afford the ability resect challenging tumors requiring complex renal reconstruction. The renal functional and oncologic outcomes are promising at a median follow-up of 22 months, but longer follow-up is required.

Initial Experience With Robot Assisted Partial Nephrectomy for Multiple Renal Masses

PURPOSE We evaluated the feasibility of performing robot assisted partial nephrectomy in patients with multiple renal masses and examined the results of our initial experiences. MATERIALS AND METHODS We reviewed the records of 10 patients with multiple renal masses who underwent attempted robot assisted partial nephrectomy within the last 2 years. Demographic information, and intraoperative, perioperative and renal function outcome data on these patients were reviewed. RESULTS A total of 24 tumors in 9 patients were removed with robot assistance. There was 1 open conversion with successful completion of partial nephrectomy. Of the patients 70% had a known hereditary renal cancer syndrome and the remainder had multifocal disease with unknown germline genetic alterations. Frozen section from the tumor bed evaluated in 5 of 10 cases was negative. One patient experienced urinary leak postoperatively, which resolved by postoperative day 9 without intervention. Of the 24 robotically resected masses 22 were malignant. Our most recent 3 patients underwent successful partial nephrectomy without hilar clamping, obviating the need for warm ischemia. Overall renal function was unchanged at most recent followup with a minimal decrease in operated kidney differential function. CONCLUSIONS Robot assisted partial nephrectomy for multiple renal masses was feasible in our early experience. Patient selection is paramount for successful minimally invasive surgery. Robot assisted partial nephrectomy without hilar clamping, especially in the hereditary patient population in which repeat ipsilateral partial nephrectomy may be anticipated, appears promising but requires further evaluation.

Salvage robotic-assisted radical prostatectomy : initial results and early report of outcomes

To evaluate the initial results of salvage robotic‐assisted radical prostatectomy (SRARP) after recurrence following primary radiotherapy (RT) for localized prostate cancer.

Functional and Oncologic Outcomes of Partial Adrenalectomy for Pheochromocytoma in Patients With von Hippel-Lindau Syndrome After at Least 5 Years of Followup

PURPOSE Although the safety and feasibility of partial adrenalectomy in patients with von Hippel-Lindau syndrome have been established, long-term outcomes have not been examined. In this study we evaluate the recurrence and functional outcomes in a von Hippel-Lindau syndrome cohort treated for pheochromocytoma with partial adrenalectomy with a followup of at least 5 years. MATERIALS AND METHODS We reviewed the records of patients with von Hippel-Lindau syndrome treated with partial adrenalectomy for pheochromocytoma at the National Cancer Institute. Demographic, germline mutation status, surgical indication, oncologic and functional outcome data were collected. Local recurrence was defined as radiographic evidence of recurrent tumor on the ipsilateral side of partial adrenalectomy. Patients were considered steroid dependent if they required steroids at most recent followup. RESULTS A total of 36 partial adrenalectomies for pheochromocytoma were performed in 26 patients with von Hippel-Lindau syndrome between September 1995 and December 2003. Of these cases 23 were performed open and 13 were performed laparoscopically. Prior surgical history was obtained for all patients. At a median followup of 9.25 years (range 5 to 46) metastatic pheochromocytoma had not developed in any patients. In 3 patients (11%) there were 5 local recurrences treated with surgical extirpation or active surveillance. All recurrences were asymptomatic and detected by radiographic imaging on followup. In addition, 3 of 26 patients (11%) subsequently required partial adrenalectomy for pheochromocytoma on the contralateral adrenal gland. In the entire cohort only 3 patients became steroid dependent (11%). CONCLUSIONS Outcomes of partial adrenalectomy in patients with von Hippel-Lindau syndrome with pheochromocytoma are encouraging at long-term followup and should be recommended as a primary surgical approach whenever possible. Adrenal sparing surgery can obviate the need for steroid replacement in the majority of patients. Local recurrence rates appear to be infrequent and can be managed successfully with subsequent observation or intervention.

Robot Assisted Laparoscopic Partial Adrenalectomy: Initial Experience

OBJECTIVES To evaluate the feasibility of performing robot-assisted laparoscopic partial adrenalectomy (RALPA) in patients seen at the National Cancer Institute and report the results of our initial experience. METHODS We reviewed the records of patients with adrenal masses who underwent attempted RALPA from July of 2008 until January of 2010. Demographic, perioperative, and pathologic data were collected. The functional and early oncological outcomes were examined by the need for steroid replacement and development of recurrent disease, respectively. RESULTS Ten patients underwent a total of 13 attempted RALPAs for removal of 19 adrenal tumors. There was one open conversion with successful completion of partial adrenalectomy. Of the patients, 80% had a known hereditary syndrome predisposing them to adrenal tumors. One patient had bilateral multifocal adrenal masses with unknown germ line genetic alteration and 1 patient had a sporadic adrenal mass. Of the 19 tumors removed, 17 were pheochromocytoma and 2 were adrenal-cortical hyperplasia. Two patients underwent partial adrenalectomy on a solitary adrenal gland, with one subsequently requiring steroid replacement postoperatively. On postoperative imaging, all but one operated adrenal gland demonstrated contrast enhancement. No patient developed local recurrence at a median follow-up of 16.2 months (range, 2-29). CONCLUSIONS RALPA appears safe and feasible in our early experience. Only 1 patient in our series required steroid replacement. Local recurrence rates are low but will require longer follow-up.

Concurrent upper and lower urinary tract robotic surgery: strategies for success

Associate Editor

Robot-assisted laparoscopic partial adrenalectomy for pheochromocytoma: the National Cancer Institute technique.

BACKGROUND Partial adrenalectomy has recently been advocated to preserve unaffected adrenal tissue during resection of pheochromocytoma. OBJECTIVE To describe a robot-assisted laparoscopic partial adrenalectomy (RALPA) technique and to report on early functional and oncologic outcomes. DESIGN, SETTING, AND PARTICIPANTS From 2007 to 2010, 15 RALPA were performed on 12 consecutive patients with pheochromocytoma. Follow-up data of >1 yr are available on 11 procedures. Median follow-up for the entire cohort was 17.3 mo (range: 6-45). SURGICAL PROCEDURE Positioning and port placement is designed for adequate reach and visualization of the upper retroperitoneum. The plane between the adrenal cortex and pheochromocytoma pseudocapsule is identified visually and with laparoscopic ultrasound. The tumor is dissected away from normal adrenal cortex, preserving normal adrenal tissue. MEASUREMENTS Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. RESULTS AND LIMITATIONS Fourteen of 15 cases were completed robotically. Among 15 procedures, 4 were performed on a solitary adrenal gland. Four cases required resection of multiple tumors (up to six) with two performed in a solitary gland. The mean age of the patients was 30 yr, and the mean body mass index was 27. The mean operative time was 163 min, the median estimated blood loss was 161 ml, and the median tumor size was 2.7 cm (range: 1.3-5.5). There was one conversion to an open procedure in a patient requiring reoperation on a solitary adrenal gland. One patient who underwent RALPA on a solitary adrenal gland required postoperative steroid supplementation at last follow-up. At a median follow-up of 17.3 mo (range: 6-45), there were no recurrences or metastatic events. Study limitations include small sample size and short follow-up. CONCLUSIONS RALPA for the treatment of pheochromocytoma is feasible and safe and provides encouraging functional and oncologic outcomes, even in patients with a solitary adrenal lesion or multiple ipsilateral lesions.

Open vs. robotic-assisted radical prostatectomy: a single surgeon and pathologist comparison of pathologic and oncologic outcomes.

OBJECTIVE To compare the impact surgical technique has on clinicopathologic and oncologic outcomes among patients undergoing radical prostatectomy for clinically localized prostate cancer. MATERIALS AND METHODS Utilizing the experience of a single surgeon and pathologist, a retrospective review of 1,041 patients undergoing open (RRP) and robotic-assisted (RALP) radical prostatectomy between 1999 and 2010 with pathologic evaluation using whole-mount sectioning techniques and tumor mapping was performed from our prospective database. Differences in the incidence, location, and linear length of positive surgical margins were compared. Additionally, rates of biochemical relapse-free survival according to technique were assessed. RESULTS A total of 357 RRP and 669 RALP patients were evaluated. The overall incidence of surgical margin positivity when stratified by stage of disease and location of positive margins was nearly identical between groups for organ confined disease. The apex and posterior surfaces represented the 2 most common locations for positive margins. RALP had notably fewer positive margins in pathologic T3 disease and a statistically shorter linear length of margin positivity among all patients. Short and intermediate-term biochemical-free survival rates were identical between groups. CONCLUSIONS RALP is associated with operative oncologic control rates that compare very favorably to RRP. The data suggest that in the hands of an experienced surgeon, RALP has oncologic outcomes that are at least as good if not better than RRP.

Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes.

To evaluate the utility of robotic repair of injuries to the ureter or bladder from obstetrical and gynaecological (OBGYN) surgery