Robotic radical prostatectomy (RARP) is a standardized treatment for localized prostate cancer, which provides better functional outcomes and similar oncological outcomes compared to open approaches. ...Here, we share our experience of 12,000 RARPs by describing the outcomes of the procedure in terms of positive surgical margin (PSM), continence, and potency as well as by presenting our detailed surgical technique with recent modifications. On cancer control, the PSM rates were 5.8% and 26.1% in T2 and T3, respectively. On the premise of not compromising oncologic outcomes, a tailored approach to individual patients is essential. Even if an extracapsular extension is suspected, neurovascular bundle (NVB) tailoring can be applied using an anatomical landmark to preserve maximal nerve tissue with a negative margin. We developed a nomogram as a useful tool for deciding the degree of tailoring. For improvements of functional outcomes, we used athermal retrograde early release with a toggling technique, wherein the nerve dissection from the bottom helps with blood loss and allows for smooth NVB releasing. Additionally, we recently performed a new minimal apical dissection/lateral prostatic fascia preservation technique. As a result, our 1-week continence rate was 37% and the 6-week rate was 77.6%. In addition, the potency rates in our study were 69%, 82%, and 92% at 3 months, 6 months, and 1 year, respectively (preoperative Sexual Health Inventory for Men scores >21 & bilateral full nerve spared).
Objective To better use virtual reality robotic simulators and offer surgeons more practical exercises, we developed the Tube 3 module for practicing vesicourethral anastomosis (VUA), one of the most ...complex steps in the robot-assisted radical prostatectomy procedure. Herein, we describe the principle of the Tube 3 module and evaluate its face, content, and construct validity. Materials and Methods Residents and attending surgeons participated in a prospective study approved by the institutional review board. We divided subjects into 2 groups, those with experience and novices. Each subject performed a simulated VUA using the Tube 3 module. A built-in scoring algorithm recorded the data from each performance. After completing the Tube 3 module exercise, each subject answered a questionnaire to provide data to be used for face and content validation. Results The novice group consisted of 10 residents. The experienced subjects (n = 10) had each previously performed at least 10 robotic surgeries. The experienced group outperformed the novice group in most variables, including task time, total score, total economy of motion, and number of instrument collisions ( P <.05). Additionally, 80% of the experienced surgeons agreed that the module reflects the technical skills required to perform VUA and would be a useful training tool. Conclusion We describe the Tube 3 module for practicing VUA, which showed excellent face, content, and construct validity. The task needs to be refined in the future to reflect VUA under real operating conditions, and concurrent and predictive validity studies are currently underway.
To review the most used robot-assisted cutaneous urinary diversion (CUD) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new ...consistent images
A non-systematic review of the literature with the keywords “bladder cancer”, “cutaneous urinary diversion”, and “radical cystectomy” was performed.
Twenty-four studies of intracorporeal ileal conduit (ICIC) and two of intracorporeal Indiana pouch (ICIP) were included in the analysis. Regarding ICIC, the patients’ age ranged from 60 to 76 years. The operative time to perform a urinary diversion ranged from 60 to 133 min. The total estimated blood loss ranged from 200 to 1 117 mL. The rate of positive surgical margins ranged from 0% to 14.3%. Early minor and major complication rates ranged from 0% to 71.4% and from 0% to 53.4%, respectively. Late minor and major complication rates ranged from 0% to 66% and from 0% to 32%, respectively. Totally ICIP data are limited to one case report and one clinical series.
The most frequent type of CUD is ICIC. Randomized studies comparing the performance of the different types of CUD, the performance in an intra- or extracorporeal manner, or the performance of a CUD versus orthotopic ileal neobladder are lacking in the literature. To this day, there are not enough quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used CUD with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images for each technique.
Focal therapy (FT) for prostate cancer is less invasive than radical treatment but carries a risk of recurrence. Salvage robot-assisted radical prostatectomy (S-RARP) is a possible option after FT ...failure.
To evaluate the impact of FT on functional and oncological outcomes following S-RARP.
In a retrospective analysis of data from a prospectively collected institutional database, 53 patients who underwent S-RARP following failure of focal ablation were selected as group I; patients who had whole-gland ablation and external beam therapy were excluded. This group was matched to a control sample (matched at ratios of 1:1, 1:2, 1:3, 1:4) of men who had undergone primary RARP, using age, prostate-specific antigen (PSA), PSA density, body mass index, Sexual Health Inventory for Men score, American Urological Association symptom score, Charlson comorbidity index, prostate weight, preoperative Gleason score (GS), and history of smoking as variables.
S-RARP after FT was performed using a standardized technique developed at our institute with the da Vinci Xi Surgical System.
Oncological and functional outcomes were compared between the S-RARP and primary RARP groups.
There was no difference in estimated blood loss (p = 0.8) between the 1:1 matched groups, but operating room time was significantly longer for S-RARP (p = 0.007). The primary RARP group had a higher proportion of patients who underwent a full nerve-sparing procedure. The S-RARP group had higher incidence of positive surgical margins (40% vs 15%; p = 0.008), GS ≥8 (25% vs 15%; p = 0.07), and positive lymph node status (9.4% vs 5.7%; p = 0.02). There was no significant difference in overall complications between the groups. The primary RARP group had a higher incidence of lymphocele drainage after surgery (15% vs 0%; p = 0.006). The main limitation of the study is its retrospective design.
S-RALP after FT failure is feasible; however, surgery following FT leads to poorer oncological and functional outcomes. Despite the targeted nature of FT, significant nonfocal collateral damage is evident in tissues surrounding the prostate, which in turn translates to poorer functional outcomes after S-RARP.
We studied the surgical challenges during robot-assisted removal of the prostate after previous focal treatment (FT) for prostate cancer and compared the outcomes to those for robot-assisted prostate removal in patients who had no previous FT. We found that this technique is safe and effective with a limited risk of complications, but poor urinary and sexual functional outcomes.
Study Type – Therapy (case series)
Level of Evidence 4
What’s known on the subject? and What does the study add?
Between December 2005 and January 2010, 200 consecutive patients with prostate cancer ...received RALP performed by a single surgeon. Only one case with Clavien grade II complication due to gouty arthritis. The complication rate was 1%. We suggested that patient with history of gouty arthritis need to prescribe preventive colchicine.
OBJECTIVE
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To analyse the learning curve for reducing complications of robotic‐assisted laparoscopic radical prostatectomy (RALP) performed by a single surgeon in Taiwan.
PATIENTS AND METHODS
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Complication rates were prospectively assessed in 200 consecutive patients undergoing RALP (Group I: cases 1–50; Group II: cases 51–100; Group III: cases 101–150 and Group IV: cases 151–200).
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Complications were classified using the Clavien system: grade I: deviation normal postoperative course without treatment; grade II: drug or bedside treatment; grade III: endoscopic or surgical intervention; grade IV: life‐threatening problem; and grade V: death.
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Operative parameters and peri‐operative complications were evaluated, including operative and console time, blood loss and transfusion rate, Gleason scores, positive surgical margin (PSM) rate, specimen volume, tumour size, tumour percentage, node positive rate and intra‐ and postoperative complications.
RESULTS
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RALP console time was gradually lowered from Group I to Group IV (P < 0.05). Significantly less blood loss occurred after every 50 cases of RALP (Group I 275 mL, Group II 179 mL, Group III 145 mL, Group IV 102 mL, P < 0.001).
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Blood transfusion incidence was 8%, 4%, 2% and 0% in Groups I, II, III and IV, respectively.
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Complication rates were 18%, 12%, 18% and 0% in Groups I, II, III and IV, respectively.
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Major complications (grade III–IV) were 6%, 2%, 4% and 0% in Groups I, II, III and IV, respectively.
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Bowel injury occurred in three cases (Group II: 1; Group III: 2); one received intra‐operative repair without sequelae and two received a transient colostomy and later colostomy closure.
CONCLUSIONS
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The learning curve for every 50 cases of RALP showed significantly less blood loss and blood transfusion rate.
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The learning curve for significantly decreasing complications is 150 cases.
Objective To investigate whether propagation of robotic technology into urologic practice and training programs has improved baseline urology resident trainee robotic skills. Design Questionnaires ...were completed by each urology resident trainee participating in a training course and asked about access to robotic simulation, robot experience, and console time. Baseline resident trainee scores on the Mimic Robotic Simulator (Mimic Technologies, Inc., Seattle, WA) from 27 participants of 2012 course were compared with the 2015 scores of 34 trainees on 4 standard Mimic exercises using Wilcoxon rank-sum tests. p = 0.05 or less were considered statistically significant. Participants and Setting Totally, 34 resident trainees from 17 programs in the Southeast Section of the American Urological Association participated in an annual 2-day robotic training course. Results Overall score, economy of motion score, and time to complete exercise were all significantly better in the 2015 trainee group compared with the 2012 trainee group (p < 0.001) for the Peg Board 1, Camera Targeting 2, and Energy Dissection exercises. Overall scores for needle targeting improved between 2012 and 2015 (p = 0.04). Trainee access to a simulator was not associated with overall score on any of the 4 exercises in the 2015 group. In the 2015 group, actual robotic console time was associated with better overall scores in Camera Targeting 2 (p = 0.02) and Peg Board 1 (p = 0.04). Conclusions Baseline resident trainee performance on basic robotic simulator exercises has improved over the past 3 years irrespective of robotic simulator access or console time.
PURPOSERecently, the modified apical dissection (MAD) technique in robot-assisted laparoscopic radical prostatectomy (RARP) has shown excellent functional outcomes but has never been rigorously ...validated at various institutions. This study aimed to evaluate the effect of MAD on early continence and potency compared with the anterior suspension stitch (SS) technique. MATERIALS AND METHODSA total of 100 patients who underwent RARP with SS and 100 who underwent RARP with MAD by a single surgeon were propensity score matched and retrospectively compared for continence and potency recovery at 1 week and 1, 3, 6, 9, and 12 months. RESULTSContinence was reached in 20.6%, 33.3%, 67.2%, 74.1%, 81.1%, and 83.0% of patients in the SS group, compared with 49.2%, 73.3%, 86.8%, 96.6%, 100.0%, and 100.0% in the MAD group at postoperative 1 week and 1, 3, 6, 9, and 12 months, respectively. In the SS group, potency rates were 0.0%, 20.0%, 50.0%, 66.7%, 75.0%, and 83.3%; in the MAD group, the rates were 50.0%, 90.0%, 88.9%, 100.0%, 100.0%, and 100.0%. Recovery of continence was higher in the MAD group within the first 6 months (p=0.005, <0.010, 0.041, 0.016 at 1 week, 1, 3, and 6 months). There were no significant differences in potency recovery rates between the two groups (all p≥0.05). CONCLUSIONSThe MAD technique results in earlier recovery of continence compared with the SS technique.
Indocyanine green is a fluorescent molecule with wide ranging applications in minimally invasive urological surgery. This article explores the utility of ICG assisted intraoperative fluorescence in ...robotic urology.
Despite the rapid increase in the use of robotic surgery in urology, the majority of ureteric reconstruction procedures are still performed using laparoscopic or open approaches. This is primarily ...due to uncertainty regarding the advantages of robotic approaches over conventional ones, and the unique difficulty in identifying the specific area of interest due to the lack of tactile feedback from the current robotic systems. However, with the potential benefits of minimal invasiveness, several pioneering reports have been published on robotic surgery in urology. By reviewing the literature on this topic, we aimed to summarize the techniques, considerations, and consistent findings regarding robotic ureteral reconstruction in adults. Robotic applications for ureteral surgery have been primarily reported for pediatric urology, especially in the context of relieving a congenital obstruction in the ureteral pelvic junction. However, contemporary studies have also consistently demonstrated that robotic surgery could be a reliable option for malignant, iatrogenic, and traumatic conditions, which generally occur in adult patients. Nevertheless, the lack of comparative studies on heterogeneous hosts and disease conditions make it difficult to determine the benefit of the robotic approach over the conventional approach in the general population; thus, qualified prospective trials are needed for wider acceptance. However, contemporary reports have demonstrated that the robotic approach could be an alternative option for ureteral construction, even in the absence of haptic feedback, which can be compensated by various surgical techniques and enhanced three-dimensional visualization.
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