Robot-assisted Laparoscopic Approach Research Articles

Robot-Assisted Laparoscopic Nephrectomy and Contralateral Ureteral Reimplantation in Children

Robot-assisted laparoscopic surgery (RALS) has expanded the role for minimally invasive surgery within pediatrics. RALS may be particularly beneficial for the treatment of children with a refluxing nonfunctioning renal moiety and contralateral vesicoureteral reflux. In this report, we describe a single RALS procedure, which includes both nephrectomy or partial nephrectomy, and contralateral extravesical ureteral reimplantation (EVUR). A retrospective review was performed of four patients who underwent RALS nephrectomy/partial nephrectomy and concurrent EVUR in one setting. Procedures were performed by a single surgeon using a robot-assisted laparoscopic approach. Four ports were used in a transperitoneal approach with patient positioning changed without moving the robotic system between the nephrectomy and reimplant. We described the technique and assessed its safety and efficacy. All cases were treated with the single RALS approach. Mean patient age was 2.3 years. Three patients underwent a nephrectomy and one a lower pole partial nephrectomy. The mean estimated blood loss was 16 mL, mean operative time was 291 minutes, and mean length of stay was 2.3 days. There was one case of postoperative ureteral obstruction that was treated with 3 weeks of ureteral stenting without further sequela. Overall, the mean follow-up time was 21 months and follow-up renal ultrasonographs and radionuclide cystograms were normal in all patients. A single RALS procedure that combines nephrectomy/partial nephrectomy and EVUR offers a novel approach to a clinical dilemma that often requires two operations. In this small series, RALS was safe and efficacious. We recommend routine Double-J stenting for the solitary reimplanted ureter.

Robot-Assisted Excision of a Retroperitoneal Mass Between the Left Renal Artery and Vein

Extra-adrenal pheochromocytomas are rare. Minimally invasive techniques have been utilized for incidentally discovered masses with successful results. We present a case of a 64-year-old female with a 3.5-cm mass located between her left renal artery and vein, treated by a 4-port robot-assisted transperitoneal laparoscopic approach. Careful dissection of the tumor away from the renal hilum was accomplished without major vascular injury. A pedicle to the tumor was identified and ligated. The pathology demonstrated a benign pheochromocytoma. To our knowledge, this is the first report of a peri-hilar excision of a pheochromocytoma using this approach. Extra-adrenal pheochromocytomas are rare and can present in difficult locations. While surgical excision may be challenging, the da Vinci Robot may be used effectively and safely for the treatment of these perihilar masses.

Prostatectomie totale laparoscopique standard versus laparoscopique robot-assistée : étude comparative sur les résultats fonctionnels urinaires

To compare urinary functional outcomes after LP prostatectomy or robotic assisted laparoscopic prostatectomy performed by a single surgeon regarding to his initial experience. Between March 2005 and April 2007, 247 consecutive patients underwent radical prostatectomy, either by LP approach (125) or by robotic-assisted laparoscopic (RALP) approach (122). The only criteria to chose robot or not, was the Robot Da Vinci's availability. There was no statistical difference between the two groups in terms of preoperative characteristics. The continence rate was 83% in PL group versus 81% in RALP group. More precisely, among men wearing at least one pad, 71% of patients in PL groups wear one pad/day versus 87% of patients in RALP group. Multivariate analysis on continence appears to be in favors of RALP group (Odd Ratio 2.1 [CI: 0,86-5,48]). Incontinence appears to be less severe and frequent in the RALP group. In practice, surgeon's impression of the robot's interest is evident, but more important number of patients and longer follow-up is necessary.

Aspects techniques de la pyéloplastie laparoscopique robot-assistée

From 2000, the robot-assisted laparoscopic approach has been developed for the management of ureteropelvic junction obstruction (UJO) with equivalent outcomes to conventional laparoscopic access regarding functional results. This system has simplified the suturing and has improved the precision of operative technique. The main surgical steps of the transperitoneal laparoscopic robot-assisted pyeloplasty are as follows: four or five port arrangement; initial dissection and early identification of the ureteropelvic junction; renal pelvis section; transection of the ureter and preparation of a spatula; continuous posterior suture; confection of a handle racket suture; placement of a double J stent; ending of the anastomosis. Outcomes after robotic and pure laparoscopic pyeloplasties are equivalent nowadays. Despite the financial cost, it seems easier and technically feasible and accessible for surgeons accustomed to the laparoscopic techniques and even beginners to learn the robotic technique if the system is available in their institution with success rate (radiologic and clinical) almost similar with those obtain with open techniques.

The natural history of voiding function after robot-assisted laparoscopic radical prostatectomy

Objectives We report the natural history of voiding function in men with clinically localized prostate cancer after robot-assisted laparoscopic radical prostatectomy (RLRP), describing the trend of functional recovery, which is currently not well described using the robot-assisted laparoscopic approach. Materials and methods We determined the impact on voiding function by prospectively evaluating 100 consecutive men who underwent RLRP between May 2005 and December 2006 and compared their reported International Prostate Symptom Score (IPSS) and Quality of Life (QOL) scores at 3, 6, and 12 months with preoperative scores after surgery. Patients with preoperative IPSS of 0-7 and 8-35 were defined as having mild lower urinary tract symptoms (LUTS) and moderate to severe LUTS, respectively. Results Continence was achieved in 82%, 87%, and 91% of men at 3, 6, and 12 months after RLRP, respectively. There were statistically and clinically significant improvements in both IPSS and QOL preoperative scores at all studied time points for patients with moderate to severe preexisting LUTS. The mean IPSS scores for these patients preoperatively and at 3, 6, and 12 months after surgery were 14.1, 5.2, 3.0, and 2.9, respectively and the corresponding mean QOL scores were 3.4, 2.1, 1.6, and 1.6, respectively. Patients with mild preexisting LUTS showed no statistically significant improvement in IPSS at 3 and 6 months after surgery but significant improvement was found at 1 year ( P = 0.04). Conclusions Good continence recovery is expected in most patients undergoing RLRP. Patients with moderate to severe preexisting LUTS can expect early and clinically significant symptom and QOL improvements after RLRP. Patients with mild preexisting LUTS show significant symptom improvement at 1 year.

Robotic-Assisted Laparoscopic Extended Pelvic Lymph Node Dissection for Prostate Cancer: Surgical Technique and Experience with the First 99 Cases

BackgroundTo date, there is still a paucity of data in the literature on robotic-assisted laparoscopic extended pelvic lymph node dissection (RALEPLND) in patients with prostate cancer. ObjectiveTo assess the technical feasibility of RALEPLND and to present our surgical technique. Design, setting, and participantsFrom April 2006 to March 2008, we performed RALEPLND in 99 patients prior to robotic-assisted laparoscopic radical prostatectomy. Indications for RALEPLND were a prostate-specific antigen (PSA) ≥10 ng/ml or a preoperative Gleason score ≥7. The data were evaluated retrospectively. Surgical procedureThe transperitoneal approach was used in all cases. In order to gain optimal access to the common iliac bifurcation, the five trocars were placed in a more cephalad position than in patients undergoing radical prostatectomy without RALEPLND. After identification of important landmarks, the lymphatics covering the external iliac vein, the obturator lymphatic packet, and the lymphatics overlying the internal iliac artery were removed on both sides. MeasurementsThe total lymph node yield, the frequency of lymph node metastases, and the complication rate. Results and limitationsThe median patient age was 64 yr (range: 45–78). The median preoperative PSA level was 7.7 ng/ml (range: 1.5–84.6). The median number of lymph nodes harvested was 19 (range: 8–53). In 16 patients (16%), we found lymph node metastasis. Complications occurred in seven patients (7%). ConclusionsRALEPLND is feasible, and its lymph node yield is well in the range of open series. The robotic-assisted laparoscopic approach in itself does not seem to limit a surgeon's ability to perform a complete extended pelvic lymph node dissection.

Robotic-assisted Laparoscopic Approach for Posterior Bladder Neck Dissection and Placement of Pediatric Bladder Neck Sling: Initial Experience

Bladder neck sling cystourethropexy is a common procedure used to correct intrinsic sphincter deficiency in children with spinal dyspharism. Various modifications of the procedure have been made but all involve circumferential dissection of the bladder neck and proximal urethra. The posterior dissection can be challenging and can result in injury to the rectum, urethra, or vagina. The posterior approach to the bladder neck as reported by Lottmann and later by de Badiola addresses these potential complications. Using these principles of the posterior approach, we performed a robotic-assisted laparoscopic placement of an acellular human dermal allograft bladder neck sling in 2 patients. We present our initial experience regarding this surgical technique. The diagnosis of intrinsic sphincter deficiency was established in 2 female patients, aged 9 and 10 years. Both patients had a neurogenic bladder secondary to spina bifida. Video urodynamics confirmed adequate bladder compliance and intrinsic sphincter deficiency. Robotic-assisted laparoscopic placement of a bladder neck sling was performed in both patients. Both procedures were completed intracorporeally. The mean blood loss was 20 mL. The mean operative time was 189 minutes. No intraoperative or postoperative complications occurred. The mean hospital stay was 3 days (range 2-4). The follow-up ranged from 13 to 22 months. Postoperative studies revealed continued low-pressure, compliant bladders and stable upper tracts. At last follow-up, the 2 patients were using catheterization without difficulty and were continent. The robotic-assisted laparoscopic approach to performing bladder neck dissection and placement of a bladder neck sling in children is technically feasible.

Cost Analysis of Radical Retropubic, Perineal, and Robotic Prostatectomy

Radical prostatectomy can be performed via a retropubic, perineal, laparoscopic, or robot-assisted laparoscopic approach. Our goal was to evaluate the actual charges incurred at our institution with patients undergoing retropubic prostatectomy (RRP), perineal prostatectomy (RPP), and robot-assisted laparoscopic prostatectomy (RALP). We retrospectively reviewed all prostatectomy patients treated over a 22-month period (February 2002-December 2004). The case log included 78 RALPs, 16 RRPs, and 16 RPPs. Hospital charges were broken down into operative and nonoperative amounts. Operative times, blood loss, and length of hospital stay were all determined from the patient medical record. The robotic charges were divided further into the initial and final 20 cases. There were significantly higher overall charges for patients undergoing RALP. The operative charges encountered during the robotic "learning curve" were substantially higher than those during our most recent 20 cases. This reduction seemed to correlate directly with the decreasing operative time. The mean operative time for RALP was 262 minutes (range 150-679 minutes). The mean operative time decreased to 225 minutes for our last 20 cases. In contrast, the mean times for RRP and RPP were similar, 202 minutes (range 142-348 minutes) and 196 minutes (range 105-337 minutes), respectively. Robot-assisted prostatectomy is associated with substantially higher operative and total hospital charges in addition to the capital expense incurred by the hospital in acquiring and maintaining the robotic system. The operative charges did decrease substantially (27%) once the learning curve had been overcome. Perineal prostatectomy, in experienced hands, remains the most cost-effective procedure, with lower operative costs and shorter times. There was no significant difference in the nonoperative charges in the three treatment groups secondary to the short hospital stay.

Robot-assisted laparoscopic renal artery aneurysm reconstruction

We report the surgical management of an expanding 2.5-cm left-sided renal artery aneurysm using a robotic-assisted laparoscopic approach. Using the da Vinci surgical robotic system, we resected the aneurysm, and the anterior-inferior branch of the renal artery was reconstructed with an end-to-end anastomosis. The operative time was 360 minutes, hospitalization length of stay was 3 days, and postoperative analgesic requirements were minimal. Follow-up imaging and functional analysis demonstrated resolution of the aneurysm and preservation of renal function. This technique highlights the ability of surgical robotics to expand indications for minimally invasive surgery in complex cases.

Laparoscopic vesicovaginal fistula repair with robotic reconstruction

To describe, to our knowledge, the first case report of robotic-assisted laparoscopic repair of a vesicovaginal fistula. A 44-year-old woman presented with a vesicovaginal fistula after vaginal hysterectomy. She had been noted to have a bladder injury that was repaired at that time. A vesicovaginal fistula developed several weeks later, and she was referred for repair. The location of the fistula was deemed amenable to repair using a robot-assisted laparoscopic approach. The total operative time was 280 minutes, including placement of ureteral catheters and repositioning. The estimated blood loss was 50 mL. The fistula was repaired using robot-assisted laparoscopic techniques without complications, and the patient went home on the second postoperative day. The Foley catheter was removed 2 weeks postoperatively. The patient continued to void normally without recurrence at 16 weeks of follow-up. Laparoscopic repair of vesicovaginal fistulas has not gained widespread acceptance owing to its technical difficulty. We describe a minimally invasive laparoscopic approach using the DaVinci robotic system to repair a vesicovaginal fistula.