Objectives
To evaluate the feasibility of robot‐assisted single‐port (SP) transvesical partial prostatectomy (TVPP) using a novel purpose‐built SP surgical platform in a pre‐clinical model.
Methods
...The cadavers were placed in the lithotomy position. A 3‐cm midline incision was made in the suprapubic area 4‐cm from the symphisis pubis. After opening the Retzius space, an access mini device (GelPOINT; Applied Medical, Rancho Margarita, CA, USA) was introduced percutaneously directly into the bladder. The da Vinci SP1098 robotic platform (Intuitive Surgical, Sunnyvale, CA, USA) was docked to the GelPOINT by inserting a novel SP cannula through the GelSeal Cap. The surgical steps for en bloc anterior prostatectomy were performed in the following order: (i) antegrade dissection of the transition zone at the bladder neck; (ii) lateral excision of the peripheral zone; and (iii) urethrovesical anastomosis. Primary outcomes, such as intra‐operative complications, rate of conversion to standard techniques and operating times, were recorded.
Results
The SP‐TVPP procedure was technically completed in three male cadavers. All cases were completed successfully using the da Vinci SP1098 surgical system without conversion or the need for additional ports. There were no intra‐operative complications. The mean total operating time was 49.3 min.
Conclusion
Robot‐assisted TVPP is feasible using a novel purpose‐built SP surgical platform in a cadaver model. Future clinical evaluation in humans is needed for assessment on patients with anterior localized prostate cancer. Prospective comparison with other surgical platforms and standard techniques is warranted.
Abstract Background The idea of performing a laparoscopic procedure through a single abdominal incision was conceived with the aim of expediting postoperative recovery. Objective To determine the ...clinical feasibility and safety of single-port urologic procedures by using a novel robotic surgical system. Design, setting, and participants This was a prospective institutional review board–approved, Innovation, Development, Exploration, Assessment, Long-term Study (IDEAL) phase 1 study. After enrollment, patients underwent a major urologic robotic single-port procedure over a 3-wk period in July 2010. The patients were followed for 3 yr postoperatively. Intervention Different types of urologic surgeries were performed using the da Vinci SP Surgical System. This system is intended to provide the same core clinical capabilities as the existing multiport da Vinci system, except that three articulating endoscopic instruments and an articulating endoscopic camera are inserted into the patient through a single robotic port. Outcome measurements and statistical analysis The main outcomes were the technical feasibility of the procedures (as measured by the rate of conversions) and the safety of the procedures (as measured by the incidence of perioperative complications). Secondary end points consisted of evaluating other key surgical perioperative outcomes as well as midterm functional and oncologic outcomes. Results and limitations A total of 19 patients were enrolled in the study. Eleven of them underwent radical prostatectomy; eight subjects underwent nephrectomy procedures (partial nephrectomy, four; radical nephrectomy, two; and simple nephrectomy, two). There were no conversions to alternative surgical approaches. Overall, two major (Clavien grade 3b) postoperative complications were observed in the radical prostatectomy group and none in the nephrectomy group. At 1-yr follow-up, one radical prostatectomy patient experienced biochemical recurrence, which was successfully treated with salvage radiation therapy. The median warm ischemia time for three of the partial nephrectomies was 38 min. At 3-yr follow-up all patients presented a preserved renal function; none had tumor recurrence. Study limitations include the small sample and the lack of a control group. Conclusions We describe the first clinical application of a novel robotic platform specifically designed for single-port urologic surgery. Major urologic procedures were successfully completed without conversions. Further assessment is warranted to corroborate these promising findings. Patient summary A novel purpose-built robotic system enables surgeons to perform safely and effectively a variety of major urologic procedures through a single small abdominal incision. Trial registration The study was registered on www.ClinicalTrials.gov (NCT02136121).
ObjectiveTo compare the perioperative outcomes of robotic partial nephrectomy (RPN) with laparoscopic PN (LPN) performed for small renal masses (SRMs), in a large multi‐institutional series and to ...define a new composite outcome measure, termed ‘optimal outcome’ for the RPN group.
Patients and Methods
Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high‐volume centres from 2004 to mid‐2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of ≤25 min. The ‘optimal outcome’ was defined as achievement of Trifecta with addition of 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading. Univariable and multivariable analysis were used to identify factors predicting Trifecta and ‘optimal outcome’ achievement.
Results
In all, 1185 RPN and 646 LPN met our inclusion criteria. Patients in the RPN group were older and had a higher median Charlson comorbidity index and higher R.E.N.A.L. nephrometry score. The RPN group had lower warm ischaemia time (18 vs 26 min), overall complication rate (16.2% vs 25.9%), and positive surgical margin rate (3.2% vs. 9.7%). There was a significantly higher Trifecta rate for RPN (70% vs 33%) and the rate of achievement of ‘optimal outcome’ for the RPN group was 38.5%.
Conclusions
In this large multi‐institutional series RPN was superior to LPN for perioperative surgical outcomes measured by Trifecta. Patients in the RPN group had better outcomes for all three components of Trifecta compared with their LPN counterparts. Our more strict definition for ‘optimal outcome’ might be a better tool for assessing perioperative and functional outcomes after minimally invasive PN. This tool needs to be externally validated.
Objectives
To describe the step‐by‐step techniques for robot‐assisted ureteric reimplantation performed using the Vinci SP® surgical system (Intuitive Surgical, Sunnyvale, CA, USA), including ...different case scenarios with an educational purpose.
Materials and Methods
Three consecutive patients diagnosed with distal benign ureteric strictures were counselled for ureteric reimplantation and consented to undergo surgery performed using the da Vinci SP surgical system. Demographics and peri‐operative outcomes were collected after institutional review board approval (IRB 13‐780). Patients provided informed consent having received an explanation for the adoption of the novel platform. The first patient was a woman referred to our institution for a left distal ureteric stricture after total hysterectomy for uterine fibroids with ureteric injury. The second patient was a man with BPH and recurrent UTIs, who was diagnosed with a 1.5‐cm bladder stone and a large bladder diverticulum compressing the left distal ureter. The third patient was a man diagnosed with bilateral uretero‐enteric anastomoses stricture status after radical cystectomy with orthotopic ileal neobladder urinary diversion for bladder cancer.
Results
The procedures were successfully completed. An extra port through a separate skin incision for the bedside assistant was placed for the first two procedures. In such cases, this additional port was used electively from the start of the procedure and did not represent a change in the treatment plan. Moreover, the port wound was used to accommodate the drainage. The bilateral ureteric reimplantation, however, was completed according to a pure single‐site approach (no extra ports were placed out of the GelSeal cap). The mean operating times were 165, 150 and 180 min, respectively. Blood loss was 50 mL in all cases. No intra‐operative complications occurred. Patients were discharged on postoperative days 1, 1 and 2, respectively, with normal serum creatinine levels. Neither transfusions nor major complications occurred.
Conclusion
Robot‐assisted reconstructive surgery for benign distal ureteric strictures is feasible and safe using the da Vinci SP surgical system.
Abstract Context Centres worldwide have been performing partial nephrectomies laparoscopically for greater than a decade. With the increasing use of robotics, many centres have reported their early ...experiences using it for nephron-sparing surgery. Objective To review published literature comparing robotic partial nephrectomy (RPN) with laparoscopic partial nephrectomy (LPN). Evidence acquisition An online systematic review of the literature according to Cochrane guidelines was conducted from 2000 to 2012 including studies comparing RPN and LPN. All studies comparing RPN with LPN were included. The outcome measures were the patient demographics, tumour size, operating time, warm ischaemic time, blood loss, transfusion rates, length of hospital stay, conversion rates, and complications. A meta-analysis of the results was conducted. For continuous data, a Mantel-Haenszel chi-square test was used; for dichotomous data, an inverse variance was used. Each was expressed as a risk ratio with a 95% confidence interval p < 0.05 considered significant. Evidence synthesis A total of 717 patients were included, 313 patients in the robotic group and 404 patients in the laparoscopic group (seven studies). There was no significant difference between the two groups in any of the demographic parameters except for age (age: p = 0.006; sex: p = 0.54; laterality: p = 0.05; tumour size: p = 0.62, tumour location: p = 57; or confirmed malignant final pathology: p = 0.79). There was no difference between the two groups regarding operative times ( p = 0.58), estimated blood loss ( p = 0.76), or conversion rates ( p = 0.84). The RPN group had significantly less warm ischaemic time than the LPN group ( p = 0.0008). There was no difference regarding postoperative length of hospital stay ( p = 0.37), complications ( p = 0.86), or positive margins ( p = 0.93). Conclusions In early experience, RPN appears to be a feasible and safe alternative to its laparoscopic counterpart with decreased warm ischaemia times noted.
Abstract Background Robotic single-site retroperitoneal renal surgery has the potential to minimize the morbidity of standard transperitoneal and multiport approaches. Traditionally, technological ...limitations of non–purpose-built robotic platforms have hindered the application of this approach. Objective To assess the feasibility of retroperitoneal renal surgery using a new purpose-built robotic single-port surgical system. Design, setting, and participants This was a preclinical study using three male cadavers to assess the feasibility of the da Vinci SP1098 surgical system for robotic laparoendoscopic single-site (R-LESS) retroperitoneal renal surgery. Surgical procedure We used the SP1098 to perform retroperitoneal R-LESS radical nephrectomy ( n = 1) and bilateral partial nephrectomy ( n = 4) on the anterior and posterior surfaces of the kidney. Improvements unique to this system include enhanced optics and intelligent instrument arm control. Access was obtained 2 cm anterior and inferior to the tip of the 12th rib using a novel 2.5-cm robotic single-port system that accommodates three double-jointed articulating robotic instruments, an articulating camera, and an assistant port. Measurements The primary outcome was the technical feasibility of the procedures, as measured by the need for conversion to standard techniques, intraoperative complications, and operative times. Results and limitations All cases were completed without the need for conversion. There were no intraoperative complications. The operative time was 100 min for radical nephrectomy, and the mean operative time was 91.8 ± 18.5 min for partial nephrectomy. Limitations include the preclinical model, the small sample size, and the lack of a control group. Conclusions Single-site retroperitoneal renal surgery is feasible using the latest-generation SP1098 robotic platform. While the potential of the SP1098 appears promising, further study is needed for clinical evaluation of this investigational technology. Patient summary In an experimental model, we used a new robotic system to successfully perform major surgery on the kidney through a single small incision without entering the abdomen.
Purpose We report a comparative analysis of a large series of laparoscopic and robotic partial nephrectomies performed by a high volume single surgeon at a tertiary care institution. Materials and ...Methods We retrospectively reviewed the medical charts of 500 patients treated with minimally invasive partial nephrectomy by a single surgeon between March 2002 and February 2012. Demographic and perioperative data were collected and statistically analyzed. R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in mm, anterior/posterior and location relative to polar lines) nephrometry score was used to score tumors. Those scored as moderate and high complexity were designated as complex. Trifecta was defined as a combination of warm ischemia time less than 25 minutes, negative surgical margins and no perioperative complications. Results Two groups were identified, including 261 patients with robotic and 231 with laparoscopic partial nephrectomy. Demographics were similar in the groups. The robotic group was significantly more morbid (Charlson comorbidity index 3.75 vs 1.26), included more complex tumors (R.E.N.A.L. score 5.98 vs 7.2), and had lower operative (169.9 vs 191.7 minutes) and warm ischemia (17.9 vs 25.2 minutes) time, intraoperative (2.6% vs 5.6%, each p <0.001) and postoperative (24.53% vs 32.03%, p = 0.004) complications, and positive margin rate (2.9% vs 5.6%, p <0.001). Thus, a higher overall trifecta rate was observed for robotic partial nephrectomy (58.7% vs 31.6%, p <0.001). The laparoscopic group had longer followup (3.43 vs 1.51 years, p <0.001) and no significant difference in postoperative changes in renal function. Main study limitations were the retrospective nature, arbitrary definition of trifecta and shorter followup in the RPN group. Conclusions Our large comparative analysis shows that robotic partial nephrectomy offers a wider range of indications, better operative outcomes and lower perioperative morbidity than laparoscopic partial nephrectomy. Overall, the quest for trifecta seems to be better accomplished by robotic partial nephrectomy, which is likely to become the new standard for minimally invasive partial nephrectomy.
Abstract Background Robotic technology is being increasingly adopted in urologic surgery. Objective To describe a contemporary surgical technique and report cumulative surgical outcomes of ...robot-assisted laparoscopic partial nephrectomy (RALPN) at our tertiary care institution. Design, setting, and participants Medical charts of consecutive patients who underwent RALPN between June 2006 and November 2011 were reviewed from a prospectively maintained, institutional review board-approved database. Surgical procedure The main steps of our current surgical technique are described in this video tutorial: patient positioning and trocar placement; bowel mobilization; hilar dissection; tumor identification and demarcation; clamping of the hilum; tumor excision; renorraphy; hilar unclamping; and tumor retrieval. Outcome measurements and statistical analysis Patients’ characteristics and main surgical outcomes were analyzed. Results and limitations A total of 400 patients (mean age: 58.5 yr, mean body mass index: 30.7 kg/m2 ) were included in this analysis. Mean renal tumor size was 3.17 cm (standard deviation SD: 1.64) and mean RENAL score was 7.2 (SD: 2). Six patients (1.5%) presented with a solitary kidney. Mean total operative time was 190.3 min (SD: 57), and mean warm ischemia time was 19.2 min (SD: 10.72). In 36 cases (9%), an unclamped hilum technique was used. After a mean follow-up of 12.4 mo (SD: 12.2), there was a decline of −9.2 ml/min per 1.73 m2 (SD: 26.56) in estimated glomerular filtration rate. Most renal masses were malignant (74.5%), and the overall mean tumor size was 3.05 cm (SD: 1.66). Renal cell carcinoma with a clear cell histology represented the most frequent malignant diagnosis (64.4% of cases). A positive margin was observed in nine cases (2.25%). A total of 11 intraoperative complications (2.7%) occurred, and a conversion to open or laparoscopic PN was required in six cases (1.5%). A postoperative complication occurred in 61 cases (15.3%), the majority of them being low grade. Conclusions The standardization of each surgical step has allowed for optimization of RALPN and ultimately improved its outcomes and expanded its indications.
Objectives
To describe the features of the novel, purpose‐built da Vinci model SP1098 single‐port robotic platform and to describe a step‐by‐step approach for perineal prostatectomy and pelvic lymph ...node dissection in a cadaver model.
Methods
Three single‐port robotic radical perineal prostatectomies and two pelvic lymph node dissections were performed on three male cadavers to assess the feasibility of the SP1098 da Vinci robotic platform. The steps in the procedure included division of the rectourethralis muscle, splitting of the levator ani muscles bilaterally, opening of Denonvilliers fascia with dissection of the seminal vesicles, apical dissection and urethral division, anterior and lateral dissection with ligation of prostatic pedicles, bilateral pelvic lymph node dissection, and creation of the new vesico‐urethral anastomosis. The main outcomes assessed were operating time per step, total operating time, intra‐operative complications and need for conversion to conventional or open techniques.
Results
No conversions were required. No intra‐operative complications were seen. The median (range) operating time for performing single‐port robotic radical perineal prostatectomy and pelvic lymph node dissection was 210 (180–240) min.
Conclusions
We have shown the feasibility and efficacy of a novel, purpose‐built robotic system in performing single‐port radical perineal prostatectomy and describe, for the first time, the feasibility of robotic perineal lymph node dissection. This single‐port system will facilitate single‐port applications and allow surgeons to perform major urological operations via a small, single incision while preserving triangulation and optics, and eliminating clashing between instruments. Future clinical studies are needed to support these encouraging outcomes.
