Robot-assisted Approaches Research Articles

The 8th American Urological Association and the Japanese Urological Association International Affiliate Society Meeting

The 8th American Urological Association and the Japanese Urological Association International Affiliate Society Meeting

Advances in Minimally Invasive Repair of Vesicovaginal Fistulas

Over the past 20years, the discussion concerning vesicovaginal fistula (VVF) repair has evolved from strictly transabdominal/transvaginal to including minimally invasive surgeries. The original natural orifice approach through the vagina allows for VVF repair with decreased morbidity and minimal convalescence with success rates upwards of 90%. For surgeries that involve a narrowed/stenotic vagina or a need for a concomitant abdominal procedure, transadominal surgery can be performed by laparoscopic or robot-assisted laparoscopic approaches. Success rates in large series are upwards of 86%. Difficulties such as an increased learning curve and vesicovaginal plane dissection have been overcome with innovations such as the robotic platform and cutting to the light with vaginoscopy. While still in its infancy in VVF repair, single site surgery has also been utilized with reasonable success. Although minimally invasive surgery offers numerous advantages, the most successful approach will still be the surgery with which the VVF surgeon is most familiar.

IJU this issue

It is my great pleasure to edit and publish the special issue of International Journal of Urology, entitled “Recent topics relevant to radical prostatectomy”. As you know, the concept of radical prostatectomy has drastically changed in recent years. For example, a detailed characterization of the pelvic anatomy has made a substantial contribution for refining the surgical technique of this surgery. In addition, the introduction of a robot-assisted system in the field of this surgery resulted in the paradigm shift of the procedure of radical prostatectomy; that is, the majority of radical prostatectomies in North America are currently carried out using robot-assisted techniques, and the proportion of robot-assisted radical prostatectomy in Japan is also markedly increasing. Considering these circumstances, I believe that this timely-edited special issue will be of interest to the readers of International Journal of Urology. This issue consists of five Invited Review Articles, one Review Article, four Original Articles and one Short Communication. These studies describe the hot topics associated with radical prostatectomy, and the content of this issue might help provide useful information to resolve and overcome several problems regarding radical prostatectomy. This issue starts with a review focusing on the recent progress in the knowledge of pelvic anatomy by Hinata et al. (Yonago, Japan). They precisely described the updated findings on anatomical landmarks related to radical prostatectomy, including the carvenous nerve, prostatic fascia, Denonvillers' fascia, endopelvic fascia and apex of the prostate. Subsequently, the current status of robot-assisted radical prostatectomy was comparatively described with those of other surgical approaches by Lim et al. (Seoul, Korea). It was emphasized in this review that robot-assisted radical prostatectomy offers at least equivalent oncological and functional outcomes when compared with open and laparoscopic prostatectomies. Four other excellent reviews are included in this issue. Kaiho et al. (Sendai, Japan) provided detailed information on the significance of phosphodiesterase type 5 inhibitors in penile rehabilitation following radical prostatectomy. Ischia and Gleave (Vancouver, Canada) reported the role of surgery for men with high-risk prostate cancer based on the advantageous features of radical prostatectomy for this type of cohort, especially favorable local control of the primary tumor without an increase in morbidity. Miyake and Fujisawa (Kobe, Japan) described the current status of prognostic prediction following radical prostatectomy. They emphasized the limitations of available systems and the development of new tools incorporating conventional, as well as molecular, biomarkers. Moran et al. (Dublin, Ireland) carried out a meta-analysis for comparing robot-assisted radical prostatectomy with open and laparoscopic approaches, and found some differences between robot-assisted and open approaches in favor of the robotic surgery. Consistent with the Review Articles, four Original Articles and one Short Communication are provided in this issue. Sato et al. (Sapporo, Japan) reported the importance of partners' cooperative attitude in the maintenance of patients' sexual desire and motivation after radical prostatectomy. Kaneko et al. (Tokyo, Japan) identified high body mass index and prostate weight as independent predictors of prolonged total operative time in laparoscopic radical prostatectomy. Okamura et al. (Nagoya, Japan) carried out a multi-institutional study and showed that when standardized goals in perioperative care are recommended, both setting and practice of perioperative care in men undergoing radical prostatectomy were significantly improved. May et al. (Munich, Germany) demonstrated a promising role of Schwann cell-mediated delivery of glial cell line-derived neurotrophic factor for the treatment of erectile dysfunction after cavernous nerve injury, such as that during radical prostatectomy. Sugihara et al. (Iwata, Japan) carried out a comparative evaluation for perioperative outcomes and costs between open and laparoscopic radical prostatectomies, and found several benefits of the laparoscopic approach over open surgery. None declared.

Robotic surgery for the treatment of early-stage lung cancer

Video-assisted thoracic surgery (VATS) is a minimally invasive approach with several advantages over open thoracotomy for resectable lung cancer. However, VATS use is limited mainly because of rigid instruments and limited vision. Robot technology appears to overcome these limitations. This review examines the recent literature on the only commercially available robotic system (da Vinci) and comparatively assesses its advantages and disadvantages for the treatment of lung cancer. Retrospective studies demonstrate that robot-assisted lobotomy is feasible and safe. Limited long-term results indicate oncological radicality similar to that of open and VATS approaches. Several different robotic techniques are currently employed. Indications for robotic lung resection may be more extensive than those for VATS. Randomized controlled trials are not available. Robot-assisted approaches to lung cancer resection and lymph node dissection appear to offer comparable radicality and safety to VATS and open surgery. More intuitive movements, greater flexibility and high-definition, three-dimensional vision render surgery easier for the surgeon, with shorter learning curve than VATS. High capital and running costs, limited instrument availability and long operating times are important disadvantages. Entry of competitor companies should drive down costs. Studies are required to assess quality of life, morbidity, oncological radicality and cost-effectiveness.

Robotic Approaches for Rehabilitation of Hand Function After Stroke

The goal of this review was to discuss the impairments in hand function after stroke and present previous work on robot-assisted approaches to movement neurorehabilitation. Robotic devices offer a unique training environment that may enhance outcomes beyond what is possible with conventional means. Robots apply forces to the hand, allowing completion of movements while preventing inappropriate movement patterns. Evidence from the literature is emerging that certain characteristics of the human-robot interaction are preferable. In light of this evidence, the robotic hand devices that have undergone clinical testing are reviewed, highlighting the authors' work in this area. Finally, suggestions for future work are offered. The ability to deliver therapy doses far higher than what has been previously tested is a potentially key advantage of robotic devices that needs further exploration. In particular, more efforts are needed to develop highly motivating home-based devices, which can increase access to high doses of assisted movement therapy.

Pancreatic, endocrine and bariatric surgery: The role of robot-assisted approaches

Please cite this article in press as: Brunaud L, et al. Pancreatic, endocrine and bariatric surgery: The role of robot-assisted approaches. Journal of Visceral Surgery (2011), doi:10.1016/j.jviscsurg.2011.05.006 surgery have also been carried by this groundswell. In 2010, surgery on all organs encompassed by the field of surgical endocrinology (pancreas and adrenal, parathyroid, and thyroid glands) is routinely performed by a minimally invasive laparoscopic approach, as is bariatric surgery [1—7]. For most surgeons, however, laparoscopy is still limited to procedures of relatively low (e.g., cholecystectomy or appendectomy) or intermediate (fundoplication, colectomy, splenectomy, or gastric bypass) complexity [8]. The causes of this limitation are mainly related to the technical difficulties encountered with laparoscopy, for which the surgeon uses long instruments without articulated ends, which thus provide only four degrees of freedom. Such instruments modify the performance of the surgical procedure as compared to open surgery, where surgeons can position their bodies and use their shoulders, elbows, wrists, and finger joints for optimal control of the surgical movements. In addition, the physician views laparoscopy on a two-dimensional screen, which has no depth of field; this makes some dissection and suturing procedures more difficult. The camera is not manipulated by the surgeon but by an assistant, which can also affect the quality of the field of vision. Finally, alignment of the visual field with the ends of the instruments is rarely achieved; this problem creates a significant fatigue factor that interferes with the precision of the surgeon’s hand movements [9]. In this context, the development of robotic surgery is part of a process intended to give patients the advantages of laparoscopy while endeavoring to overcome the aforesaid difficulties routinely encountered by laparoscopic surgeons. Robotic surgery consists of ‘‘simply’’ placing a computer interface between patient and surgeon to optimize the feasibility and quality of the surgical procedure. It is therefore actually laparoscopic surgery whose feasibility, indications, and results are ‘‘optimized’’ compared with conventional laparoscopic surgery [10].

Recurrent nasopharyngeal carcinoma: surgical salvage vs. additional chemoradiation

The primary treatment modality of nasopharyngeal carcinoma (NPC) is radiation or chemoradiation. With the application of conformal radiation and appropriate chemotherapeutic agents, there was marked improvement in the outcome. Despite this, a small number of patients still develop residual or recurrent disease either in the neck or at the primary site. In recent years there are many developments in the disciplines of surgery, radiation and medical oncology which are applicable for the management of residual or recurrent NPC. It is timely to review the applicability and efficacy of the various therapeutic options. The theme of the literature review included the management of these recurrent or residual diseases in the neck or nasopharynx with open or endoscopic or robot-assisted surgical approaches. The application of radiation techniques such as intensity modulated radiotherapy, stereotactic radiation and brachytherapy was also included. The use of chemotherapy and targeted agents is also reviewed. In general, the size, extent and location of the residual or recurrent NPC together with the biological behaviour of the tumour determine the optimal therapy. The surgical and clinical oncological expertise applied optimally will give the best outcome.

Long‐term anatomical and functional results of laparoscopic promontofixation for pelvic organ prolapse

To assess the long-term anatomical and functional outcomes of laparoscopic promontofixation (LP) for pelvic organ prolapse (POP), and the long-term safety of LP, as POP is a common problem in women of all ages, with treatment including vaginal, abdominal, laparoscopic or robot-assisted surgical approaches. This was a retrospective study of the first consecutive 186 women who underwent LP for POP, with or without stress urinary incontinence (SUI), from January 1998 to December 2002 in one centre. Those patients with concurrent SUI had LP with a Burch colposuspension or tension-free vaginal tape (TVT). The recurrence rate of POP was evaluated by physical examination at follow-up visits and by the patients, using a postal, unvalidated self-applied questionnaire (SAQ). Patients' urinary, sexual and digestive functions, overall satisfaction about surgery and quality of life, were evaluated with SAQ. All 186 patients had LP, with concomitant Burch (25) or TVT (100) procedures. The median (interquartile range) follow-up was 60 (48-71) months. In all, 71% of the patients attended their follow-up visits and the success rate was 92.4%. Eight patients were re-operated because of recurrent POP. The SAQ response rate was 95%; 91.1% and 79.8% of responders were satisfied or very satisfied after their surgery, and with their quality of life, respectively; women were unsatisfied or very unsatisfied because of recurrence of POP (seven), urinary symptoms (five) or constipation (two). Patients complained of recurrent POP (10.8%), persistent or recurrent UI (27.3% of the women treated with Burch and 21.1% with TVT), and transient constipation (20%). Over half of the women (50.6%) were not sexually active and 5.4% developed dyspareunia. The long-term complication rate was 6%; there were five vaginal mesh erosions. POP treated with LP offers excellent long-term results with low recurrence and morbidity rates, and a good quality of life.

Bypass pyeloplasty: Description of a procedure and initial results

Introduction and objective Dismembered pyeloplasty is the surgical technique of choice for open, laparoscopic and/or robot-assisted repair of ureteropelvic junction obstruction (UPJO). We describe a new technique, bypass pyeloplasty, ideally suited for the high inserting ureter, and present initial results. Patients and methods A wide 1–2-cm side-to-side anastomosis is created between the dilated and elastic portion of the ureter just distal to the UPJO and the lower and dependent portion of the hydronephrotic renal pelvis. The UPJ is not disturbed and the renal pelvis is not surgically reduced. Since 2004, of 27 patients requiring surgery for UPJO, 7 underwent bypass pyeloplasty. The indications for surgery included increasing hydronephrosis or decreasing individual renal function in four, pain in two and pyelonephritis in one. The remaining 20 underwent a classic dismembered pyeloplasty. Results During a mean follow-up of 26 months, the anteroposterior diameter of the repaired kidney decreased by a mean of 55%. The individual renal function in the repaired kidney improved in two and remained stable in the remainder. Conclusion These favorable initial results justify further exploration of this simplified technique and its adaptation for laparoscopic and robot-assisted approaches. Bypass pyeloplasty may be a more physiologic procedure in patients with mid to high insertion of the ureter.

The cost of radical prostatectomy: retrospective comparison of open, laparoscopic, and robot-assisted approaches.

New technologies are regularly being used for surgical treatment of prostate cancer, however the cost associated is often a secondary issue. We assessed the operative costs incurred by using the daVinci robot assisted prostatectomy (RAP) method compared to pure laparoscopic radical prostatectomy (LRP) and open radical prostatectomy (ORP). We retrospectively analyzed three techniques of radical prostatectomies: ORP, LRP, and RAP (n=70, 57, 106, respectively). The mean patient age was 53.6, 57.6, and 60 with a mean preoperative prostate specific antigen (PSA) of 7.2, 8.4, and 6.6, respectively. The mean Gleason score was 6. Operative cost was measured for each patient. Charts were reviewed to assess individual patients postoperative requirements, and hospital length of stay (LOS). Intraoperative data show costs to be higher with the RAP and LRP compared to open surgery. Average total operating room (OR) costs per case were $5410, $3876, and $1870 for RAP, LRP, and open prostatectomy, respectively. However when comparisons are made in the postoperative period with regard to LOS, there is a significant advantage of the RAP and LRP groups over open surgery (P<0.05). Intraoperative costs are highest for RAP. Both LRP and RAP are associated with a shorter hospital stay.

Prostatectomies totales rétropubiennes, laparoscopiques et robot-assistées : comparaison des suites postopératoires, des résultats anatomopathologiques et fonctionnels : à propos de 86 prostatectomies

Compare three surgical approach procedures of total prostatectomy (retropubic, transperitoneal laparoscopic and robot-assisted laparoscopic), about technical, oncological and functional results.Eighty-six patients had a total prostatectomy for localized cancer, in a unique center, performed by two expert surgeons, on a 16-months-period. Twenty nine had a retropubic, 23 a transperitoneal laparoscopic and 34 a robot-assisted (Da Vinci) surgical approach. Retrospectively, operative time, blood loss, per- and postoperative complications, duration of catheterization, length of hospital stay, in each group had been compared. The positive margin rates, the PSA levels at one and six months postoperative had been compared. The continence has also been evaluated at six months.The three groups are comparable even if the median age is significatively lower in the retropubic group (p=0.018). Duration of catheter (p<2.2 x 10(-16)), blood loss (p<3.12 x 10(-5)) and operative times support significatively the laparscopic approaches, clearer the conventional than the robot-assisted one. No significative difference has been shown about positive margin rates, even if it's higher in the robot-assisted group (p=0.37). Finally, the continence rate is quite higher in the laparoscopic groups without statistic significativity (76 % retropubic versus 96.8 % laparoscopic and 85.3 % robot-assisted).The conventional laparoscopic and robot-assisted approaches seem to present technical advantages. Nevertheless, pathologic results are shader: the positive margin rate in the robot-assisted group is higher, in particular regarding to pT2. These results are concordant with the available datas of the literature.

The use of robotically assisted surgery for treating urachal anomalies

To report the management of urachal anomalies using a robotically assisted approach. Between January 2005 and February 2006, five patients (mean age 51 years, range 24-68) were diagnosed with urachal anomalies. Two basic robot-assisted surgical approaches were used for excising the urachal anomalies: excision of the urachal remnant via partial cystectomy, and radical cystectomy for excision of urachal adenocarcinoma. All five cases were successful and the excised specimens were assessed histologically. The short-term oncological outcome in the three patients with histologically confirmed moderately differentiated adenocarcinoma showed no evidence of recurrent disease within a median interval of 8 months. Surveillance follow-up cystoscopy in the patients who had a partial cystectomy showed a well-healed bladder mucosa with no evidence of recurrence. Radical excision of the urachal tract with partial cystectomy or radical cystectomy using the da Vinci robot is safe, effective and technically feasible.