Vipul R. Patel

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.

A consensus document on robotic surgery

“Robotic surgery” originated as an imprecise term, but it has been widely used by both the medical and lay press and is now generally accepted by the medical community. The term refers to surgical technology that places a computer-assisted electromechanical device in the path between the surgeon and the patient. A more scientifically accurate term for current devices would be “remote telepresence manipulators” because available technology does not generally function without the explicit and direct control of a human operator. For the purposes of the document, we define robotic surgery as a surgical procedure or technology that adds a computer technology–enhanced device to the interaction between a surgeon and a patient during a surgical operation and assumes some degree of control heretofore completely reserved for the surgeon. For example, in laparoscopic surgery, the surgeon directly controls and manipulates tissue, albeit at some distance from the patient and through a fulcrum point in the abdominal wall. This differs from the use of current robotic devices, whereby the surgeon sits at a console, typically in the operating room but outside the sterile field, directing and controlling the movements of one or more robotic arms. Although the surgeon still maintains control over the operation, the control is indirect and effected from an increased distance. n nThis definition of robotic surgery encompasses micromanipulators, remotely controlled endoscopes, and console-manipulator devices. The key elements are enhancements of the surgeon’s abilities—be they vision, tissue manipulation, or tissue sensing—and alteration of the traditional direct local contact between surgeon and patient.

Robotic-assisted laparoscopic ureteral reimplantation with psoas hitch: a multi-institutional, multinational evaluation.

OBJECTIVESnTo report the collective experience of three multinational institutions with the use of robotics to evaluate and treat complex distal ureteral obstruction.nnnMETHODSnA total of 12 patients from The Ohio State University, Columbus, Ohio; Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium; and Hospital Sultanah Aminah, Kuala Lumpur, Malaysia underwent robotic-assisted laparoscopic ureteral reimplantation between August 2004 and July 2006. The indications for ureteral reimplantation included ureteral stricture (n = 10) and ureterovaginal fistula (n = 2). Nine patients had pathology on the left side and 4 patients had right-sided disease. Surgery was performed by three experienced laparoscopic robotic surgeons with the daVinci Surgical System.nnnRESULTSnThe mean patient age (range) was 41.3 years (19 to 67 years). The mean operative time was 208 minutes (80 to 360 minutes). The mean robot time was 173 minutes (75 to 300 minutes). The mean estimated blood loss was 48 mL (45 to 100 minutes). The mean length of hospitalization was 4.3 days (2 to 8 days). All the procedures were completed successfully robotically without open conversion. There were no intraoperative or postoperative complications. Postoperative intravenous urography and Mercapto Acetyl TriGlycine 3 showed normal findings in 10 patients and a mild residual hydronephrosis in 2 patients. After a mean follow-up of 15.5 months, all patients were asymptomatic of their initial disease state.nnnCONCLUSIONSnThis multi-institutional, multinational experience illustrates that ureteral reimplantation with psoas hitch can be performed safely and effectively to treat lower tract ureteral obstruction.

Robotic assisted laparoscopic radical prostatectomy: a review of the current state of affairs.

Open retropubic radical prostatectomy is the gold standard treatment for localised prostate cancer. However, the procedure has inherent morbidity associated to it. Therefore, less invasive surgical techniques have been sought, one such alternative is robotic‐assisted laparoscopic radical prostatectomy. The advantages provided by robotic technology have the potential to minimise patient morbidity while improving both functional and oncological outcomes. Although it is a recent technological advancement, robotic surgery has shown an increasing rate of adoption worldwide. Currently more than 30,000 patients have undergone this procedure worldwide. We present a review of the available literature on robotic‐assisted laparoscopic radical prostatectomy.

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.

The use of high resolution optical coherence tomography to evaluate robotic radical prostatectomy specimens.

OBJECTIVEnOptical coherence tomography (OCT) is a unique technology, developed to provide high resolution, cross sectional images of human tissue. The objective of this study was to explore the feasibility of OCT for the evaluation of positive surgical margins and extra capsular extension in robotic prostatectomy specimens and compare it to histopathology.nnnMATERIALS AND METHODSnRadical prostatectomy was performed in 100 patients. Twenty OCT images of each specimen were taken from the base of the seminal vesicles (SV), apical and vesicle margins, peripheral and posterolateral area and any palpable nodule. Predictions were made regarding positive surgical margin, SV involvement, capsular invasion and compared with the final histopathology.nnnRESULTSnA total of 2000 OCT images were taken and analyzed. Out of 100 specimens, 85 had T2 disease, 15 had T3 disease with a median Gleasons score of 7 (range 6 to 9) and 10 had positive surgical margins. We predicted 21 specimens to have positive margins based on OCT images out of which 7 were truly positive and 14 were falsely positive. Based on OCT images, 79 specimens were predicted to have negative margins out of which 76 were truly negative and 3 were falsely negative. We found the sensitivity, specificity, positive predictive value and negative predictive value to be 70%, 84%, 33% and 96% respectively.nnnCONCLUSIONnOur initial feasibility study established the template for the visual OCT characteristics of the prostate, SV and cancerous tissue. The negative predictive value of evaluating surgical margins was high.

A computerized analysis of robotic versus laparoscopic task performance

IntroductionRobotic technology has been postulated to improve performance in advanced surgical skills. We utilized a novel computerized assessment system to objectively describe the technical enhancement in task performance comparing robotic and laparoscopic instrumentation.Methods and proceduresAdvanced laparoscopic surgeons (2–10 yrs experience) performed three unique task modules using laparoscopic and Telerobotic surgical instrumentation (Intuitive Surgical, Sunnyvale, CA). Performance was evaluated using a computerized assessment system (ProMIS, Dublin, Ireland) and results were recorded as time (s), path (mm) and precision. Each surgeon had an initial training session followed by two testing sessions for each module. A paired Student’s t-test was used to analyze the data.ResultsTen surgeons completed the study. 8/10 surgeons had significant technical enhancement utilizing robotic technology.ConclusionsThe ProMIS computerized assessment system can be modified to objectively obtain task performance data with robotic instrumentation. All the tasks were performed faster and with more precision using the robotic technology than standard laparoscopy.

Histopathologic Outcomes of Robotic Radical Prostatectomy

Robotically assisted laparoscopic radical prostatectomy is a minimally invasive alternative for the treatment of prostate cancer. We report the histopathologic and shortterm PSA outcomes of 500 robotic radical prostatectomies. Five hundred patients underwent robotic radical prostatectomy. The procedure was performed via a six trocar transperitoneal technique. Prostatectomy specimens were analyzed for TNM stage, Gleason’s 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 were collected every 3 months for the first year, then every 6 months for a year, then yearly. The average preoperative PSA was 6.9 (1–90) with Gleason’s score of 5 (2%), 6 (52%), 7 (40%), 8 (4%), and 9 (2%); postoperatively, histopathologic analysis showed Gleasons 6 (44%), 7 (42%), 8 (10%), and 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, and 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 it was 31% for nonorgan-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%) multifocal. 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 nonorgan-confined tumors. Of those patients with a minimum follow-up of 1 year (average 15.7 months), 95% have undetectable PSA (<0.1). Our initial experience with robotic radical prostatectomy is promising. Histopathologic outcomes are acceptable with a low overall, positive margin rate. Shortterm 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. At this time, the lack of maturity of the PSA data prevent definitive comparison to the open approach.

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]. n nIntroduction 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.

Robotically assisted laparoscopic pyeloplasty : a transatlantic comparison of techniques and outcomes

To report a comparison of two techniques of robotically assisted laparoscopic dismembered pyeloplasty (RALDP), and their associated outcomes, for treating pelvi‐ureteric junction obstruction (PUJO), evaluating the potential differences in the initial 50 cases of two centres in North America and Europe.