Objective
To compare the range of motion and ergonomic characteristics of single-port robotic instruments in the setting of the “floating” versus “flat” docking technique using the GelPOINT
®
system.
...Material and methods
The basic principle of the floating docking technique resides in the GelSeal cap and trocar (s) being 8 cm off the skin level with the Alexis
®
acting as a conduit between the trocar (s) and the body while preserving insufflation.
In the setting of a dry lab study, we measured the range of motion of one robotic instrument with the “floating” and the “flat” docking technique in two different situations depending on whether the distance between the incision and the target was more or less than 10 cm.
Results
The minimum required distances between the target and the tip of the cannula for activation of the wrist and elbow were 5 and 10 cm, respectively. When the target was near to the cannula (i.e., less than 10 cm), the floating technique was associated with a significant increase in the range of motion of the instrument in all directions. The working space volume of the instrument was increased by more than 390% (from 101 to 497 cm
3
) when the surgeon switched from flat (standard) to the floating technique in the setting of a target close (i.e., less than 10 cm) to the cannula
Conclusion
The floating docking technique is a simple and effective way to increase the working surgical space, especially in confined and narrow surgical fields with a target closer than 10 cm from the skin.
Background
Prostate cancer (PCa) is the most common malignant tumor in males and conventional imaging does not provide accurate primary staging. Prostate-specific membrane antigen (PSMA) positron ...emission tomography (PET) presents superior performance and strongly affects therapeutic choice.
Objective
The aim of this study was to evaluate the impact of PSMA PET, compared with conventional imaging methods, on the therapeutic approach in primary staging scenarios in patients with PCa treated at the Brazilian National Public Health System.
Methods
Overall, 35 patients diagnosed with PCa were evaluated using PSMA after conventional staging imaging with multiparametric magnetic resonance (MMR) and/or total abdominal computed tomography (CT) scan and bone scintigraphy (BS). The PCa extension identified by PET was compared with conventional imaging; staging changes and the management impact were then determined. PET comparison with conventional imaging, staging, and decision-making changes was analyzed using descriptive statistics.
Results
PET revealed local disease (LD) in 15 (42.9%) patients, seminal vesicle invasion (SVI) in 5 (14.3%) patients, pelvic nodal impairment (PNI) in 7 (20%) patients, pelvic and distant nodes in 3 (8.6%) patients, pelvic nodes and bone metastasis in 4 (11.4%) patients, and pelvic and distant nodes and bone metastasis in 1 (2.8%) patient. Staging changes were observed in 60% of patients, with downstaging predominance (76.2%). Volume increase was identified in 11 (31.4%) patients (only 4 related to upstaging, 36.4%). The board changed management decisions for 60% of the patients. The main limitations of this study were the sample size and its retrospective nature.
Conclusions
PSMA findings changed the management decisions in more than half of the patients, which made the majority eligible for locoregional treatment and avoided unnecessary procedures in the systemic disease scenario.
In this comparative study on robotic versus open partial nephrectomy, functional and oncologic outcomes were similar between the two techniques, with lower morbidity—especially in terms of ...complications—for robot-assisted surgery. The assessment of prognosticators for patients receiving robot-assisted partial nephrectomy may help in preoperative counseling and provides relevant data to tailor postoperative follow-up.
Current literature does not provide large-scale data regarding clinical outcomes of robot-assisted (RAPN) versus open (OPN) partial nephrectomy. Moreover, data assessing predictors of long-term oncologic outcomes after RAPN are scarce.
To compare perioperative, functional, and oncologic outcomes of RAPN versus OPN, and to investigate the predictors of oncologic outcomes after RAPN.
This study included 3467 patients treated with OPN (n = 1063) or RAPN (n = 2404) for a single cT1–2N0M0 renal mass from 2004 to 2018 at nine high-volume European, North American, and Asian institutions.
The study outcomes were short-term postoperative, functional, and oncologic outcomes. Regression models investigated the effect of surgical approach (open vs Robot assisted) on study outcomes, and interaction tests were used for subgroup analyses. Propensity score matching for demographic and tumor characteristics was used in sensitivity analyses. Multivariable Cox-regression analyses identified predictors of oncologic outcomes after RAPN.
Baseline characteristics were similar between patients receiving RAPN and OPN, with only few differences. After adjusting for confounding, RAPN was associated with lower odds of intraoperative (odds ratio OR: 0.39, 95% confidence interval CI: 0.22, 0.68) and Clavien-Dindo ≥2 postoperative (OR: 0.29, 95% CI: 0.16, 0.50) complications (both p < 0.05). This association was not affected by comorbidities, tumor dimension, PADUA score, or preoperative renal function (all p > 0.05 on interaction tests). On multivariable analyses, we found no differences between the two techniques with respect to functional and oncologic outcomes (all p > 0.05). Overall, there were 63 and 92 local recurrences and systemic progressions, respectively, with a median follow-up after surgery of 32 mo (interquartile range: 18, 60). Among patients receiving RAPN, we assessed predictors of local recurrence and systemic progression with discrimination accuracy (ie, C-index) that ranged from 0.73 to 0.81.
While cancer control and long-term renal function did not differ between RAPN and OPN, we found that the intra- and postoperative morbidity—especially in terms of complications—was lower after RAPN than after OPN. Our predictive models allow surgeons to estimate the risk of adverse oncologic outcomes after RAPN, with relevant implications for preoperative counseling and follow-up after surgery.
In this comparative study on robotic versus open partial nephrectomy, functional and oncologic outcomes were similar between the two techniques, with lower morbidity—especially in terms of complications—for robot-assisted surgery. The assessment of prognosticators for patients receiving robot-assisted partial nephrectomy may help in preoperative counseling and provides relevant data to tailor postoperative follow-up.
Robotic-assisted radical prostatectomy in patients with a history artificial urinary sphincter (AUS) placement has not been previously described. We describe the technique of extraperitoneal ...single-port robotic-assisted radical prostatectomy in a patient with a preexisting functional AUS, with emphasis on critical technical details of the procedure to prevent injury to the AUS components.
The patient was a 69-year-old male with history of total urinary incontinence after transurethral resection of the prostate managed with AUS placement in 2011. He was diagnosed with multifocal intermediate risk Gleason 3 + 4 prostate cancer and scheduled for robotic assisted radical prostatectomy (RARP) with bilateral pelvic lymph node dissection (PLND).
Extraperitoneal robotic-assisted radical prostatectomy and bilateral pelvic lymph node dissection were performed with a pure single-site approach using the da Vinci SP® surgical system. There were no intraoperative complications. There was no damage to the adjacent organs or the AUS components. Operative time was 180 min with negligible blood loss. The Foley catheter was removed on postoperative day 7 and the AUS was reactivated afterwards. Patient could void without any difficulty and was pad free when AUS was active. Histopathological examination of the specimen showed prostate adenocarcinoma with Gleason score 3 + 4 disease and unilateral extra prostatic extension (pT3a) with focally positive margins. Three-month postoperative nadir prostate specific antigen (PSA) was undetectable and the patient remained pad-free during the same period.
Extra-peritoneal robotic-assisted RP in a patient with preexisting AUS by using a single-port robotic platform is safe and feasible. When compared to multi-port robotic instrumentation, the single-port robotic arms enter from the same incision, which may result in decreased out-of-field instrument contact with the AUS hardware.
•Duplication of the classic open simple prostatectomy by direct transvesical access to the prostate adenoma.•Surgery in supine position.•A single 3 cm midline incision for transvesical access, total ...extraperitoneal surgery without the need for bivalving the bladder.•An alternative for minimally invasive surgical management of patients with large prostate adenoma.•Associated bladder conditions (e.g. bladder stone or diverticulum) can simultaneously be addressed.
Objective
To describe our technique of extraperitoneal single‐port (SP) robot‐assisted radical prostatectomy (RARP) and present our clinical experience with the first 10 cases.
Patients and Methods
...In all, 10 consecutive patients diagnosed with localised prostate cancer underwent extraperitoneal SP‐RARP using the da Vinci SP® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Exclusion criteria included previous surgery through an infra‐umbilical midline incision, prostate size >100 g, or preoperative evidence of extraprostatic disease. All surgeries were performed by a single surgeon with previous experience of >3000 cases in robotic surgery. Demographics and perioperative information were collected including: operative time, estimated blood loss (EBL), complications, length of stay, and days with Foley catheter. The extraperitoneal SP‐RARP is performed as follows. Firstly, a 3‐cm incision ~2 cm below the umbilicus is made. Dissection of the extraperitoneal space is achieved using a kidney shaped Spacemaker™ balloon (Covidien, Dublin, Ireland), placed through the infra‐umbilical incision caudally reaching the retropubic space. Thereafter, the balloon is deployed; the space is created and verified under direct vision with a laparoscopic endoscope. A GelPOINT® mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) is inserted and a dedicated 25‐mm multichannel port is placed with a 12‐mm accessory laparoscopic port through the gel‐seal cap into the same incision. The da Vinci SP surgical platform robot is docked with the patient in a supine position. RARP is performed replicating the technique previously described for multi‐arm platforms or transperitoneal SP‐RARP. No drain and no additional assistant ports were utilised.
Results
The patient's ages ranged between 48 and 70 years, and the mean preoperative prostate‐specific antigen (PSA) level was 9 ng/mL. No conversions or intraoperative complications were recorded. The median (interquartile range) operative time was 197.5 (185.5–229.7) min. EBL ranged between 50 and 400 mL, six patients were discharged on the same day as the surgery and the median time with a Foley catheter after surgery was 8 days.
Conclusions
Extraperitoneal SP‐RARP is a feasible and safe surgical option to treat localised prostate cancer. In our early experience, promising results and possible advantages were found such as: a small single incision, no additional ports, no Trendelenburg positioning, minimal postoperative pain and use of opioids, and same day discharge. Further investigations need to be done to validate these advantages.
In the era of efficient value-based health care, each surgical innovation should be proven to be cost-effective for the patient and the hospital administration.
To compare the costs associated with ...robot-assisted prostatectomy using a single-port (SP) or multiport (MP) robotic platform.
Costs for surgical care for consecutive patients with localized prostate cancer treated from November 2018 to November 2019 were itemized and evaluated.
Patients were treated using either the SP (n = 78) or MP (n = 97) platform.
Demographics, perioperative data, and costs for surgical care of patients in both groups were analyzed.
The mean cost for prostatectomy was comparable between SP ($13 512 ± $1615) and MP ($13 284 ± $1360; p = 0.32). The main cost differences between the groups were the cost of hospitalization, which was lower in the SP group (p < 0.001), offset by the cost of disposables in the operating room, which was higher in the SP group (p < 0.001). The mean length of stay was significantly shorter in the SP group (9.84 ± 11.3 vs 35.5 ± 29.1 h; p < 0.001) and the proportion of patients discharged home on the day of surgery was higher in the SP group (70% vs 5%; p < 0.001). The main limitation of this study is its retrospective design.
Overall, the costs for SP and MP prostatectomy are comparable. The higher SP cost for consumable surgical materials is offset by the lower cost associated with hospitalization, which was largely due to a shorter hospital stay after SP surgery.
In this report, we found that implementation of the new single-port robotic platform for radical prostatectomy was not associated with higher surgical care costs compared to conventional multiport surgery.
Overall costs for single-port and multiport robot-assisted prostatectomy are comparable. The higher cost for surgical consumables for single-port surgery is offset by the lower cost associated with hospitalization, largely because of a shorter hospital stay after pure single-site surgery. Implementation of the new single-port platform for radical prostatectomy was not associated with higher costs of surgical care compared to conventional multiport surgery.
To present a comprehensive report regarding our experience with single-port robotic surgery in our first 100 consecutive patients. We describe the diversity of procedures that can be performed with ...this platform as well as the challenges and complications we had with the application of this novel technology.
Between September 2018 and August 2019, data on 100 patients who underwent single-port robotic surgery were consecutively collected. Preoperative, intraoperative and early postoperative outcomes after various urologic procedures were recorded and analyzed.
During the study period, 100 patients (age range 35-84 years; 88 88% Male) underwent various single-port robotic surgeries for different indications (Retroperitoneal n = 14, Pelvic surgeries n = 86). Transperitoneal (n = 37), extraperitoneal (n = 53) and transvesical (n = 10) approaches have been used to access the target organs. Of these procedures, 73 (73%) were for different oncological indications: Radical prostatectomy (n = 60), Partial nephrectomy (n = 6), Retroperitoneal lymph node dissection (n = 1) and Radical cystectomy with intracorporeal diversion (n = 6). Surgery was successfully completed in all but 1 patient, in whom the surgery was converted to open surgery due to dense adhesions and failure to progress. Grades II-III postoperative complications were detected in (n = 9) patients.
The purpose-built single-port robotic platform can be safely incorporated into the minimally invasive armamentarium. A wide range of pelvic and retroperitoneal urological procedures can be done with different approaches using this platform. Randomized trials with adequate sample size and postoperative follow up period is advisable for further evaluation of the outcomes and to determine the added value of this emerging technology.
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