Robot-assisted Pelvic Surgery Research Articles

Upper extremity contact pressure measurement in robot-assisted pelvic surgery

Upper extremity complications are often a problem in robot-assisted pelvic surgery (RAPS) with the lithotomy-Trendelenburg position (LT-position). This study focused on upper extremity contact pressure (UEP) and examined the relationship between UEP and upper extremity complications. From May 2020 to April 2022 at the University of Tokyo Hospital, UEP was measured in 155 patients undergoing RARP and 20 patients undergoing RARC. A total of 350 sets of UEP were investigated in this study. UEP was measured using a portable interface pressure sensor (Palm Q, Cape CO., Kanagawa, Japan) in the preoperative lithotripsy position (L-position), preoperative LT-position, and postoperative L-position. UEP was increased in the preoperative LT-position than in the preoperative L-position (right side 5.2 mmHg vs. 17.1 mmHg, left side 5.3 mmHg vs. 17.1 mmHg, P < 0.001, respectively), and was decreased in the postoperative L-position than in preoperative LT-position (right side 17.1 mmHg vs. 10.8 mmHg, left side 17.1 mmHg vs. 10.6 mmHg, P < 0.001, respectively). Eleven upper extremities developed shoulder pain. UEP of the preoperative LT-position tended to be higher in the upper extremity exhibiting shoulder pain (25.6 mmHg (15.4–30.3) vs. 17.1 mmHg (12.0–24.4) P = 0.0901). UEP measurements may help prevent postoperative shoulder pain.

Impact of Surgical Experience Before Robot-assisted Partial Nephrectomy on Surgical Outcomes: A Multicenter Analysis of 2500 Patients

BackgroundRobot-assisted partial nephrectomy (RAPN) is a challenging procedure that is influenced by a multitude of factors. ObjectiveTo assess the impact of prior surgical experience on perioperative outcomes in RAPN. Design, setting, and participantsIn this retrospective multicenter study, results for 2548 RAPNs performed by 25 surgeons at eight robotic referral centers were analyzed. Perioperative data for all consecutive RAPNs from the start of each individual surgeon’s experience were collected, as well as the number of prior open or laparoscopic kidney surgeries, pelvic surgeries (open, laparoscopic, robotic), and other robotic interventions. InterventionTransperitoneal or retroperitoneal RAPN. Outcome measurements and statistical analysisThe impact of prior surgical experience on operative time, warm ischemia time (WIT), major complications, and margin, ischemia, complication (MIC) score (negative surgical margins, WIT ≤20 min, no major complications) was assessed via univariate and multivariable regression analyses accounting for age, gender, body mass index (BMI), American Society of Anesthesiologists score, PADUA score, and RAPN experience. Results and limitationsBMI, PADUA score, and surgical experience in RAPN had a strong impact on perioperative outcomes. A plateau effect for the learning curve was not observed. Prior laparoscopic kidney surgery significantly reduced the operative time (p < 0.001) and WIT (p < 0.001) and improved the MIC rate (p = 0.022). A greater number of prior robotic pelvic interventions decreased WIT (p = 0.011) and the rate of major complications (p < 0.001) and increased the MIC rate (p = 0.011), while prior experience in open kidney surgery did not. One limitation is the short-term follow-up. ConclusionsMastering of RAPN is an ongoing learning process. However, prior experience in laparoscopic kidney and robot-assisted pelvic surgery seems to improve perioperative outcomes for surgeons when starting with RAPN, while experience in open surgery might not be crucial. Patient summaryIn this multicenter analysis, we found that a high degree of experience in keyhole kidney surgery and robot-assisted pelvic surgery helps surgeons in achieving good initial outcomes when starting robot-assisted kidney surgery.

Anaesthesia-Specifi c Oxygen Transport Assessment in Robot-Assisted Pelvic Surgery: a Clinical Trial

Background. Robot-assisted pelvic surgery rapidly becomes a choice in surgeries for gynaecological oncology and urology. These interventions require special settings (pneumoperitonaeum and Trendelenburg position), which inevitably and systemically impact oxygen transport. Low oxygen delivery during surgery associates with manifold adverse outcomes. A single universal oxygen delivery threshold is impractical, as oxygen consumption must be taken into account. This study examines the effects of pneumoperitonaeum and Trendelenburg position on oxygen transport in patients of ASA functional class I–III (as per American Society of Anaesthesiologists).Materials and methods. Delivery, consumption, oxygen extraction, perioperative adverse events and type of general anaesthesia were prospectively studied in 126 adult patients.Results and discussion. Mean oxygen consumption was 242 mL/min/m2 , mean oxygen delivery — 612 mL/min/m2 . Oxygen delivery was below median 529 mL/min/m2 in 54 (43 %) patients. Perioperative adverse events developed in 36 (29 %) patients. A strong correlation (r &gt; 0.500; p&lt;0.001) between oxygen delivery and consumption was observed in 54 patients. Blood lactate level of 2.7 mmol/L at surgery end was indicative of inadequate oxygen delivery.Conclusion. No relationship was revealed between oxygen delivery and adverse perioperative events, and neither — between oxygen delivery and consumption relative to a particular anaesthetic.

Robot-assisted pelvic urologic surgeries: is it feasible to perform under reduced tilt?

To evaluate the feasibility and outcomes of performing robot-assisted pelvic surgery at a reduced angle of Trendelenburg position. This was a prospective case-control study of 67 patients in 2:1 ratio. Controls were operated with steep Trendelenburg position of 30°, whereas cases were operated using a graduated method to achieve minimal optimal angle of operating table. Various body habitus parameters, console time, blood loss, rise in mean arterial pressure (MAP) and end-tidal carbon-dioxide (ET-CO2), duration of ileus, postoperative stay and complications were recorded. All demographic profile and body habitus parameters were comparable among two groups except age which was lower in Reduced-Tilt group. Cases were operated at a mean angle of 20.5 ± 3.1° compared to 30° in control group. Rise in MAP, ET-CO2 and facial swelling were significantly low in Reduced-Tilt group compared to control. Notably blood loss, duration of ileus, postoperative stay and complications were also low in patients with Reduced Tilt. Various body habitus parameters were analysed with multiple regression analysis to predict minimal angle required for performing surgery with Reduced Tilt. BMI, xiphisterno-umbilical distance, umbilical-pubic-symphyseal distance and subcostal angle were found to predict the same. Robot-assisted pelvic surgeries can be performed in reduced Trendelenburg tilt which is associated with less hemodynamic and respiratory stress, complication rates and early postoperative recovery. BMI, subcostal angle, xiphisterno-umbilical distance and umbilical-pubic-symphyseal distance can predict the feasible angle of tilt.

Optic nerve sheath diameter-guided extubation plan in obese patients undergoing robotic pelvic surgery in steep Trendelenburg position: A report of three cases.

Robotic pelvic surgery requires steep Trendelenburg positioning with pneumoperitoneum which causes raised thoracic and intracranial pressures. In obese patients, the basal thoracic pressures are high. Increased intrathoracic pressure can decrease the cranial venous flow leading to deficient intracranial absorption of cerebrospinal fluid and a further increase in intracranial pressure. Operating times are also longer due to unfavorable anatomy. Such patients frequently have a delayed awakening from anaesthesia due to a combination of factors such as hypercapnoea, acidosis, and raised intracranial pressures. Normocapnoea can be achieved in a ventilated patient towards the end of surgery. In cases where the anaesthetic agents have been washed out and normocapnoea has been achieved, the intracranial pressure may be an important factor causing delayed emergence. The sonographically measured optic nerve sheath diameter correlates with the intracranial pressure. We report three cases of robot-assisted pelvic surgery in obese patients where we used the optic nerve sheath diameter as a guide for the timing of extubation.

Safety and Effectiveness of SAF-R, a Novel Patient Positioning Device for Robot-Assisted Pelvic Surgery in Trendelenburg Position

We found current robotic positioning devices to be inadequate and cumbersome. Furthermore, we realized there were no premarket well-designed studies to prove their safety and efficacy. In this prospective pilot study, we aimed to investigate the safety and effectiveness of a novel patient-positioning device (SAF-R) to secure the patient in Trendelenburg (T-burg) position for robot-assisted pelvic surgery. Sixteen patients undergoing robot-assisted pelvic operation in T-burg position were enrolled. Patients were positioned using SAF-R board. Pressure sensor mats were used for real-time monitoring of the contact pressures and contact area on the shoulders and calves throughout the surgery. Data collection included patients' body mass index (BMI), time needed for positioning, total time in the T-burg position, contact pressure and contact area readings from the sensor mats, and the patient shifting distance on the table. Patients were also followed for 1-month postoperatively for any position-related adverse event. The median age of the patients was 56.5 years with median BMI of 27.3. The median positioning time was 6 minutes, duration of T-burg position was 3.5 hours, and patient shift on the table was 1 cm. The contact pressure over the shoulders was in the safe range (< 80 mm Hg) before and at the end of the surgery in all cases (right: 13.12 ± 1.12 vs 20.25 ± 1.56 mm Hg, left: 12.84 ± 1.05 vs 19.60 ± 1.09 mm Hg, p = 0.001). The changes in the mean contact pressure over the calves and the mean contact area for the shoulders and calves during the T-burg position were not significantly different. No significant position-related complication was detected during follow-up. SAF-R surgical board is a safe, reliable, and timesaving positioning device for patients undergoing robotic pelvic surgery in the T-burg position.

Laparoscopic and Robot-Assisted Pelvic Surgery: Pathophysiologic Considerations for Better Patient Selection

Laparoscopic and Robot-Assisted Pelvic Surgery: Pathophysiologic Considerations for Better Patient Selection

Side-docking Technique for Robot-assisted Urologic Pelvic Surgery

To investigate the feasibility of side-docking techniques in robot-assisted urologic pelvic surgery. Six consecutive patients undergoing robot-assisted pelvic surgery participated in the study: 3 undergoing radical cystectomy for muscle-invasive bladder cancer, 1 patient undergoing ureteroneocystostomy for ureteric stricture, 1 patient undergoing partial cystectomy for urothelial cancer in a bladder diverticulum, and 1 undergoing transvesical simple prostatectomy. Each patient was placed in the lithotomy-Trendelenburg position, with the robot docked over the patient's right side. All the procedures were completed without the need for redocking. Simultaneous cystourethroscopy was performed in 1 case to localize a bladder diverticular tumor during a partial cystectomy. Manipulation of the uterus and perineum was possible by the second assistant sitting between the patients' legs. No significant collision between the robotic arms occurred. There was no Clavien-Dindo III-V complication in any case. Side docking for robot-assisted urologic pelvic surgery is a viable positioning alternative with the advantage of enhanced access to the perineum and urethra. This modified approach will be useful in robot-assisted radical cystectomy and other reconstructive urologic procedures.

Role of Robot-Assisted Pelvic Surgery

The purpose of this study was to assess the current role of robot-assisted urological surgery in the female pelvis. The recently published English literature was reviewed to evaluate this role, with special emphasis on reconstructive procedures. These included colposuspension for genuine female stress urinary incontinence, repair of female genitourinary fistulas, ureterosciatic hernias, sacrocolpopexy for vault prolapse, ureterolysis and omental wrap for retroperitoneal fibrosis, ureteric reimplantation, and bladder surgery. To date, a wide spectrum of urogynecological reconstructive procedures have been performed with the assistance of the surgical robot and have been reported worldwide. Currently, a number of female pelvic ablative and reconstructive procedures are technically feasible with the aid of the surgical robot. While the role of robot-assisted surgery for bladder cancer, ureterolysis, ureteric reimplantation, repair of genitourinary fistulas, colposuspension, and sacrocolpopexy is nearly established among urologists, other procedures, such as myomectomy, simple hysterectomy, trachelectomy, and Wertheim's hysterectomy, are still evolving with gynecologists. The advantages of robot assistance include better hand-eye coordination, three-dimensional magnified stereoscopic vision with depth perception, intuitive movements with increased precision, and filtering of hand tremors. For most of the currently performed procedures in selected patients, the robot-assisted surgical outcomes appear to be relatively superior as compared to an open and purely laparoscopic surgical procedure.