Robot-assisted Laparoscopic Radical Cystectomy Research Articles

Robotic assisted laparoscopic radical cystectomy with stentless intracorporeal modified Ves.Pa neobladder: early experience.

This study aimed at demonstrating the feasibility of robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder with stentless ureteroileal anastomosis. Pure intracorporeal robotic assisted laparoscopic technique has been recently developed with a select number of high-volume centers utilizing various operative and neobladder techniques. We reviewed the patient characteristics, operative details and perioperative courses in the two patients who have undergone robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder and one who has undergone the Hautmann W neobladder. These results were compared to other contemporary robotic neobladder series. We demonstrate technical success with similar operative and perioperative results with the modified Ves.Pa neobladder. The robotic pure intracorporeal modified Ves.Pa neobladder is a technically feasible operation and may be easier to perform compared to other neobladders. Initial experience suggests operative time and perioperative outcomes are similar to other robotic techniques.

Feasibility and safety study for the use of wound protectors during robotic radical cystectomy and ileal conduit.

Robot-assisted laparoscopic radical cystectomy (RALRC) is increasingly being performed for the treatment of muscle-invasive bladder cancer. There is increased tension while performing the ureteroileal anastomosis through a small incision. Patients are at risk to suffer wound and skin complications perioperatively due to possible contamination with bowel contents. The Alexis® retractor helps with retraction of small incisions potentially reducing tension and also reduces wound infection rates as reported in the colorectal literature. This pilot study evaluates the use of the Alexis® wound protector (WP) in RALRC with ileal conduit (IC). The WP was used in 15 consecutive patients at a single institution who all underwent RALRC with IC. All patients had preoperative bowel preparations, antibiotics, and had surgical preparation with chlorhexidine with alcohol in the standard fashion. The Alexis® device was placed following RALRC to protect the skin and fascia during ileal conduit formation. The ileal conduit was then created extracorporeally through the WP in the standard fashion. RALRC with IC was successfully completed in all 15 patients. Patients had no wound complications defined as documentation of cellulitis or hernia on progress or follow-up notes. Using our technique with the WP we had no cases of surgical site infection. Wound barrier protection has been recommended for use in colorectal surgery and we believe that these recommendations translate to RALRC with IC due to the use of bowel to form the urinary diversion. Further studies with the use of WP in this procedure are necessary to validate our findings.

Urological malignancy in Hong Kong: the trend and the practice.

In Hong Kong, urological malignancy accounted for 9.55% of all the new cases of cancer in 2012. In the male population, prostate cancer was the third most commonly diagnosed cancer, and the fifth leading cause of cancer death. Age-standardized rate of prostate cancer incidence rose from 11.5 per 100 000 men in 1992 to 28.5 per 100 000 men in 2012. On the other hand, age-standardized rate of bladder cancer incidence dropped from 6.4 per 100 000 in 2003 to 3.0 per 100 000 in 2012. The incidence of kidney cancer remained stable in recent years, with an age-standardized rate of 4.8 per 100 000 in 2012. The introduction of the robotic surgical system has made robotic-assisted laparoscopic radical prostatectomy the most common mode of surgical treatment for prostate cancer in Hong Kong. Robotic-assisted laparoscopic radical cystectomy and robotic-assisted laparoscopic partial nephrectomy have been gaining popularity in the locality. Minimal-invasive surgical techniques as well as different systemic therapies have led to revolutionary changes in the urology community in Hong Kong. The existing territory-wide surveillance of cancer incidence and mortality trends continue to provide us with clues to aetiology and the effects of improved diagnostic and treatment techniques.

A case report of Robotic assisted laparoscopic radical cystectomy with Y pouch orthotopic ileal neobladder constructed using nonabsorbable endo GIA staples

s / Urological Science 26 (2015) S50eS81 S81 mediastinum, head, and neck. We would like to present a 17 years old female with a huge pelvic mass extent to right upper quadrant of abdomen size measures in 21x5.4x8.5 CM. Debulking surgery was performed and revealed a huge ganglioneuroma of retroperitoenum, the clinical presentation, special image and pathological picture and our experience in management of huge retroperitoneal tumor with literature review. NDP119: CASE REPORT ePENILE METASTASIS OF PROSTATE ADENOCARCINOMA WITH PRIAPISM AS THE INITIAL PRESENTATION Hung-Yi Chen, Chun-Te Wu, Wen-Hsiang Chen, Cheng-chia Lin, ShianShiang Huang, Cheng-Feng Lin. Divisions of Urology, Department of Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan Case report: A 95-year-old male has underlying disease of severe prostate hyperplasia, abnormal serum prostate-specific antigen (PSA: 18.41ng/ dl) and hardness digital rectal examination were noted. Because of multiple comorbidities and bed ridden status, further prostate malignancy survey cannot be performed. Patient has long-term Foley catheteration for difficult urinary voiding treatment. He hospitalized for antibiotic treatment under the impression of urinary tract infection with initial present by gross hematuria and pyuria. However, painful priapism with adequate glans circulation noted for one week. Bedside cavernosal aspiration revealed no blood content but only debris. No evidence of sickle cell anemia via hematological study. Dorsal slit with cavernosal biopsy was performed for symptoms relief and differential diagnosis under local anesthesia. The priapism and pain improved after the shunting procedure was done. The following pathological report of biopsy tissue showed poorly differentiated adenocarcinoma. Metastatic prostate adenocarcinoma was proved by the immunohistochemical (IHC) stain which disclosed P504S positive. Further bone scan revealed no obvious bony metastasis, patient cannot complete pelvic magnetic resonance imaging (MRI) study because of poor general conditions. This patient died of another episode of pneumonia related sepsis progression l month later. Conclusion: Prostate adenocarcinoma metastasis by pelvic lymphovascular route with the presentation of lymph edema. Gross hematuria and urine retention are also common in the advanced disease. We reported an uncommon case of non-ischemic priapism by prostate cancer penile metastasis. Laparoscopy NDP120: A CASE REPORT OF ROBOTIC ASSISTED LAPAROSCOPIC RADICAL CYSTECTOMY WITH Y POUCH ORTHOTOPIC ILEAL NEOBLADDER CONSTRUCTED USING NONABSORBABLE ENDO GIA STAPLES Yuli Lee , Lipin Chiu , Yuwei Lai , Thomas Y. Hsueh , Yi-Chun Chiu , Shiou-Sheng Chen , Allen W. Chiu . Divisions of Urology, Department of Surgery, Taipei City Hospital, Taiwan; National Yang-Ming University, School of Medicine, Taiwan Background: Laparoscopic-assisted radical cystectomy with Y pouch orthotopic ileal neobladder constructed using nonabsorbable titanium staples was early reported in 2006. Herein we present the case of robotic assisted laparoscopic radical cystectomy with Y pouch orthotopic ileal neobladder constructed using nonabsorbable endo GIA staples and a brief literature review. Case Report: A 65-year-old man was admited because of pianless gross hematuria. Cystoscopy showed multiple focal cauliflower tumor. Transurethral resection of bladder tumor was performed. The pathological report showed urothelial carcinoma with muscle invasion. Computed tomography showed diffuse bladder wall thickness and no obvious lymph node metastasis. We performed robotic assisted laparoscopic radical cystectomy with U-shaped orthotopic ileal neobladder constructed using nonabsorbable endo GIA staples. In our procedure, a 50-cm ileal segment is arranged in a U shape with two segments of approximately 20 cm and two afferent limb of 5 cm. An opening is made at the lowest point of the Uileal segment on its antimesenteric border. The jaws of the endoGIA stapler are accommodated within the bowel loop and fired as low as possible, bringing together and detubularizing of each arm of the U. To complete the pouch detubularization, another small opening is made at the bottom. Then use the endo GIA, completing the U pouch. Then performed the anastomosis of the open ends of the U shape and the cutting end of urethra.Total operation time is 290 minutes and no intraoperative complication. The patient was discharged uneventfully. Post operation one year follow-up, no bladder stone and no renal function deterioration were noted Conclusion: Robotic assisted laparoscopic radical cystectomy with Ushaped orthotopic ileal neobladder constructed using nonabsorbable endo GIA staples seem a feasible, safe and rapid procedure.

Comparison with open conventional laparoscopic and robotic assisted laparoscopic radical cystectomy with urinary diversion method— 3 years experience of single team

Comparison with open conventional laparoscopic and robotic assisted laparoscopic radical cystectomy with urinary diversion method— 3 years experience of single team

Enhanced recovery protocols (ERP) in robotic cystectomy surgery. Review of current status and trends.

Open radical cystectomy with pelvic lymphadenectomy and urinary diversion is associated with a high complication rate. Robotic-assisted laparoscopic radical cystectomy is increasingly performed in many urologic surgical departments in an effort to reduce surgical stress and decrease perioperative morbidity. Robotic cystectomy survival studies demonstrate similar oncologic outcomes compared to the open procedure. Enhanced recovery protocols (ERP) after major surgery are multimodal perioperative interventions to reduce surgical stress, complications, and patient convalescence. Evidence for different ERP interventions are currently mainly from colorectal surgery and recently adapted to major urologic operations including cystectomy. Guidelines for perioperative care after open radical cystectomy for bladder cancer were recently published, but these recommendations may differ when considering a robotic approach. Therefore, we look at the current evidence for ERP in both open and robotic radical cystectomy and the potential for improving ERPs in robotic cystectomy by utilizing a totally intracorporeal robotic cystectomy approach. We also present the Karolinska ERP currently utilized in totally intracorporeal robotic cystectomy.

MP67-18 A DECADE OF ROBOTIC CYSTECTOMY: SURGICAL CHARACTERISTICS AND ONCOLOGIC OUTCOMES

You have accessJournal of UrologyBladder Cancer: Invasive IV1 Apr 2015MP67-18 A DECADE OF ROBOTIC CYSTECTOMY: SURGICAL CHARACTERISTICS AND ONCOLOGIC OUTCOMES Ali Zhumkhawala, Spencer Kozinn, Kevin Chan, Clayton Lau, Nora Ruel, Jonathon Yamzon, Bertram Yuh, Mark Kawachi, and Timothy Wilson Ali ZhumkhawalaAli Zhumkhawala More articles by this author , Spencer KozinnSpencer Kozinn More articles by this author , Kevin ChanKevin Chan More articles by this author , Clayton LauClayton Lau More articles by this author , Nora RuelNora Ruel More articles by this author , Jonathon YamzonJonathon Yamzon More articles by this author , Bertram YuhBertram Yuh More articles by this author , Mark KawachiMark Kawachi More articles by this author , and Timothy WilsonTimothy Wilson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2501AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We performed the first robotic cystectomy at our institution in 2003. Here, we present surgical and oncologic outcomes after 12 years performing this procedure. METHODS We established a prospective database to track patients undergoing robotic cystectomy who provided informed consent. Overall and disease specific survival were stratified by nodal status and pathologic stage and calculated using Kaplan-Meier analysis. RESULTS A total of 437 patients underwent robotic cystectomy between 2003 and February 2014, of whom 255 patients with a median follow up of 44 months provided informed consent for inclusion in the database. The vast majority were men (83.4%) with a median age of 70 years (IQR 63-77 years). Most patients had multiple comorbidities as demonstrated by 210 patients (82.4%) being American Society of Anesthesiologists score III or IV and median age adjusted Charlson Comorbidity Index score of 8 (IQR 5-11). Over 2/3 of patients had preoperative stage ≥cT2 with 89.8% considered high grade disease. Approximately 1/4 of patients (68 pts, 26.5%) had undergone neoadjuvant chemotherapy. Nine patients (3.5%) had previous pelvic irradiation. Median operative time was 7.2 hours (IQR 6.3-8.2) with an EBL of 387.5 mL (IQR 250-500). The most common diversion type was Studor neobladder (108 pts, 42.4%), followed by ileal conduit (88 pts, 34.5%) and Indiana pouch (58 pts, 22.7%). Nerve sparing was performed in over 1/3 of cases, either unilaterally (10 pts, 4%) or bilaterally (87 pts, 34.1%). The median length of stay was 9 days (IQR 7-13 days). 91% of patients had urothelial carcinoma, followed by adenocarcinoma (3.5%) and squamous cell carcinoma (2.4%). Positive surgical margins were rare, occurring at the bladder in 7 pts (2.7%) and urethra in 2 pts (0.8%). Final pathologic stage was ≥T2 in 62.8% of cases and 57 patients (22.4%) had lymph node positive disease. Overall and disease-specific survival were significantly worse in patients with pT3/4 disease and positive lymph nodes. (Figure 1). CONCLUSIONS Robotic cystectomy is a viable, potentially first-line, treatment option for high-risk bladder cancer. Our surgical and oncological outcomes compare well with the largest published open series. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byChang S (2015) Re: Comparing Open Radical Cystectomy and Robot-Assisted Laparoscopic Radical Cystectomy: A Randomized Clinical TrialJournal of Urology, VOL. 194, NO. 6, (1584-1585), Online publication date: 1-Dec-2015. Volume 193Issue 4SApril 2015Page: e856-e857 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ali Zhumkhawala More articles by this author Spencer Kozinn More articles by this author Kevin Chan More articles by this author Clayton Lau More articles by this author Nora Ruel More articles by this author Jonathon Yamzon More articles by this author Bertram Yuh More articles by this author Mark Kawachi More articles by this author Timothy Wilson More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Radical Cystectomy: Open vs Robotic Approach

No AccessJournal of UrologyOpposing Views1 Feb 2015Radical Cystectomy: Open vs Robotic Approach Clayton Stephen Lau, Robert H. Blackwell, and Marcus L. Quek Clayton Stephen LauClayton Stephen Lau More articles by this author , Robert H. BlackwellRobert H. Blackwell More articles by this author , and Marcus L. QuekMarcus L. Quek More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.11.079AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Propensity-matched comparison of morbidity and costs of open and robotic assisted radical cystectomies: a contemporary population based analysis in the United States. Eur Urol2014; 66: 569. Google Scholar 2 : A randomized trial of robotic assisted laparoscopic radical cystectomy. N Engl J Med2014; 371: 389. Google Scholar 3 : Lymphadenectomy at the time of robotic-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. BJU Int2011; 107: 642. Google Scholar 4 : Quality of lympadenectomy is equivalent in robotic and open cystectomy using the same template. J Urol2012; 187: 1200. Link, Google Scholar 5 : Complications after robotic assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol2013; 64: 52. Google Scholar 6 : Defining morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol2009; 5: 164. Google Scholar 7 : Early and late complications of robotic assisted cystectomy: a standardized analysis by urinary diversion type. J Urol2014; 191: 681. Link, Google Scholar 8 : Intermediate-term oncologic outcomes of robotic assisted radical cystectomy for urothelial cancer. J Endourol2014; 28: 939. Google Scholar 9 : The RAZOR trial — randomized open versus robotic cystectomy — study design and trial update. BJU Int2014; . Epub ahead of print. Google Scholar 10 : Assessing the minimum number of lymph nodes needed at radical cystectomy in patients with bladder cancer. BJU Int2009; 103: 1359. Google Scholar 11 : Impact of surgeon and volume on extended lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium (IRCC). BJU Int2013; 111: 1075. Google Scholar 12 : Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Eur Urol2010; 57: 196. Google Scholar 13 : Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. J Urol2013; 189: 474. Link, Google Scholar 14 : Lymphadenectomy with robotic cystectomy. Curr Urol Rep2013; 14: 59. Google Scholar 15 : Positive surgical margins in soft tissue following radical cystectomy for bladder cancer and cancer specific survival. J Urol2007; 178: 2308. Link, Google Scholar 16 : A comparison of postoperative complications in open versus robotic cystectomy. Eur Urol2010; 57: 274. Google Scholar 17 : Surgical margin status after robot assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. J Urol2010; 184: 87. Link, Google Scholar 18 : Matched comparison of robotic-assisted and open radical cystectomy. Urology2012; 79: 1303. Google Scholar © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 2February 2015Page: 400-402 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Clayton Stephen Lau More articles by this author Robert H. Blackwell More articles by this author Marcus L. Quek More articles by this author Expand All Advertisement PDF DownloadLoading ...

Commentary on “Robot-assisted laparoscopic vs open radical cystectomy: Comparison of complications and perioperative oncological outcomes in 200 patients.” Kader AK, Richards KA, Krane LS, Pettus JA, Smith JJ, Hemal AK, Division of Urology, UC San Diego Health System, San Diego, CA.: BJU Int 2013; 112(4):E290–4. doi:10.1111/bju.12167. [Epub 2013 Jul 1

ObjectiveTo compare perioperative morbidity and oncological outcomes of robot-assisted laparoscopic radical cystectomy (RARC) to open RC (ORC) at a single institution. Patients and methodsA retrospective analysis was performed on a consecutive series of patients undergoing RC (100 RARC and 100 ORC) at Wake Forest University with curative intent from 2006 until 2010. Complication data using the Clavien system were collected for 90 days postoperatively. Complications and other perioperative outcomes were compared between patient groups. ResultsPatients in both groups had comparable preoperative characteristics. The overall and major complication (Clavien ≥ 3) rates were lower for RARC patients at 35 vs 57% (P = 0.001) and 10 vs 22% (P = 0.019), respectively. There were no significant differences between groups for pathological outcomes, including stage, number of nodes harvested or positive margin rates. ConclusionOur data suggest that patients undergoing RARC have perioperative oncological outcomes comparable with ORC, with fewer overall or major complications. Definitive claims about comparative outcomes with RARC require results from larger, randomised controlled trials.

Robotic Radical Cystectomy—Is the Diversion the Achilles' Heel?

No AccessJournal of UrologyOpposing Views1 Dec 2014Robotic Radical Cystectomy—Is the Diversion the Achilles' Heel? Richard E. Hautmann, Harry W. Herr, Raj S. Pruthi, and Monish Aron Richard E. HautmannRichard E. Hautmann More articles by this author , Harry W. HerrHarry W. Herr More articles by this author , Raj S. PruthiRaj S. Pruthi More articles by this author , and Monish AronMonish Aron More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.09.042AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Propensity-matched comparison of morbidity and costs of open and robot-assisted radical cystectomies: a contemporary population-based analysis in the United States. Eur Urol2014; . Epub ahead of print. Google Scholar 2 : A randomized trial of robot-assisted laparoscopic radical cystectomy. New Engl J Med2014; 371: 389. Google Scholar 3 : Selection of intestinal segments for bladder substitution: physical and physiological characteristics. J Urol1988; 139: 519. Link, Google Scholar 4 : Surgery in motion: robotic-assisted laparoscopic intracorporeal urinary diversion. Eur Urol2010; 57: 1013. Google Scholar 5 : Robot-assisted nerve-sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases. BJU Int2011; 110: 434. Google Scholar 6 : Oncologic, functional, and complications outcomes of robotic-assisted radical cystectomy with totally intracorporeal neobladder diversion. Eur Urol2013; 64: 734. Google Scholar 7 : Laparoscopic-assisted radical cystectomy with U-shaped orthotopic ileal neobladder constructed using nonabsorbable titanium staples. Urology2006; 68: 193. Google Scholar 8 : The ileal neobladder: experience and results of more than 100 consecutive cases. J Urol1990; 143: 492. Abstract, Google Scholar 9 : Orthotopic bladder substitution in men. revisited: identification of continence predictors. J Urol2006; 176: 2081. Link, Google Scholar 10 : Robotic intracorporeal orthotopic ileal neobladder: replicating open surgical principles. Eur Urol2012; 62: 891. Google Scholar 11 : Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int2003; 92: 232. Google Scholar 12 : Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Eur Urol2010; 57: 196. Google Scholar 13 : Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. J Urol2013; 189: 474. Link, Google Scholar 14 : Robotic intracorporeal urinary diversion: ileal conduit. J Endourol2012; 26: 1566. Google Scholar 15 : The first 100 consecutive, robot-assisted, intracorporeal ileal conduits: evolution of technique and 90-day outcomes. Eur Urol2013; 63: 637. Google Scholar 16 : Robotic intracorporeal orthotopic neobladder during radical cystectomy in 132 patients. J Urol2014; 192: 1734. Link, Google Scholar 17 : Analysis of intracorporeal compared with extracorporeal urinary diversion after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol2014; 65: 340. Google Scholar © 2014 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byHautmann R (2017) Declining Use of Orthotopic Reconstruction Worldwide—What Went Wrong?Journal of Urology, VOL. 199, NO. 4, (900-903), Online publication date: 1-Apr-2018.Hautmann R (2016) Editorial CommentJournal of Urology, VOL. 196, NO. 5, (1556-1557), Online publication date: 1-Nov-2016. Volume 192Issue 6December 2014Page: 1601-1603 Advertisement Copyright & Permissions© 2014 by American Urological Association Education and Research, Inc.MetricsAuthor Information Richard E. Hautmann More articles by this author Harry W. Herr More articles by this author Raj S. Pruthi More articles by this author Monish Aron More articles by this author Expand All Advertisement PDF downloadLoading ...

Health-related quality of life from a prospective randomised clinical trial of robot-assisted laparoscopic vs open radical cystectomy.

To compare health-related quality-of-life (HRQoL) outcomes for robot-assisted laparoscopic radical cystectomy (RARC) with those of traditional open radical cystectomy (ORC) in a prospective randomised fashion. This was a prospective randomised clinical trial evaluating the HRQoL for ORC vs RARC in consecutive patients from July 2009 to June 2011. We administered the Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index questionnaire, validated to assess HRQoL, preoperatively and then at 3, 6, 9 and 12 months postoperatively. Scores for each domain and total scores were compared in terms of deviation from preoperative values for both the RARC and the ORC cohorts. Multivariate linear regression was used to assess the association between the type of radical cystectomy and HRQoL. At the time of the study, 47 patients had met the inclusion criteria, with 40 patients being randomised for analysis. The cohorts consisted of 20 patients undergoing ORC and 20 undergoing RARC, who were balanced with respect to baseline demographic and clinical features. Univariate analysis showed a return to baseline scores at 3 months postoperatively in all measured domains with no statistically significant difference among the various domains between the RARC and the ORC cohorts. Multivariate analysis showed no difference in HRQoL between the two approaches in any of the various domains, with the exception of a slightly higher physical well-being score in the RARC group at 6 months. There were no significant differences in the HRQoL outcomes between ORC and RARC, with a return of quality of life scores to baseline scores 3 months after radical cystectomy in both cohorts.

Robotic radical cystectomy in bladder cancer: is it the future?

Robotic radical cystectomy in bladder cancer: is it the future? Abdullah Erdem Canda,1 Ali Fuat Atmaca,1 Muhammed Ersagun Arslan,2 Murat Keske,2 Ozer Ural Cakici,2 Serdar Cakmak,2 Davut Kamaci,2 Emre Urer21Department of Urology, School of Medicine, Ankara Ataturk Training and Research Hospital, Yildirim Beyazit University, Ankara, Turkey; 2Department of Urology, Ankara Ataturk Training and Research Hospital, Ankara, TurkeyAbstract: Open radical cystectomy (RC) is the gold standard surgical approach in the management of muscle invasive bladder cancer in addition to high-grade, recurrent, noninvasive tumors. With the development of surgical robotic technology, robotic-assisted laparoscopic radical cystectomy (RARC) is increasingly being performed as a minimally invasive surgical approach. A learning curve exists with a recommended case number of at least 20 RARC procedures in order to achieve satisfying outcomes in terms of operation time, complication rate, and oncological outcomes, including positive surgical margins (SMs) and lymph node (LN) yield. In the current literature, long-term outcomes of RARC are not yet available. Due to the outcomes of the published literature, RARC seems to have satisfactory oncologic and functional outcomes in addition to acceptable complication rates. Intraoperative blood loss and transfusion rates seem to be decreased in RARC series when compared to open approaches. On the other hand, a number of authors have reported decreased complication rates but increased operation time in the robotic approach. Similar oncologic results including positive SM rates and LN yields were detected in most comparative publications. Totally intracorporeal RARC with urinary diversion is a complex procedure and the number of centers performing this type of surgery is currently very limited. Although, it is still too early to make strict conclusions about RARC, RARC with intracorporeal urinary diversion has the potential to be the future of robotic bladder cancer surgery. Therefore, further prospective and randomized studies with increased numbers of patients and with longer follow-up are needed. Lastly, RARC may be related to increased cost when compared to open surgery, although controversial reports exist about this issue.Keywords: intracorporeal urinary diversion, outcomes, open versus robotic, robotic surgery

MP15-05 HEALTH RELATED QUALITY OF LIFE FROM A PROSPECTIVE RANDOMIZED CLINICAL TRIAL OF ROBOTIC ASSISTED LAPAROSCOPIC VERSUS OPEN RADICAL CYSTECTOMY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality of Life1 Apr 2014MP15-05 HEALTH RELATED QUALITY OF LIFE FROM A PROSPECTIVE RANDOMIZED CLINICAL TRIAL OF ROBOTIC ASSISTED LAPAROSCOPIC VERSUS OPEN RADICAL CYSTECTOMY Jamie Messer, John Fitzgerald, Robert Svatek, and Dipen Parekh Jamie MesserJamie Messer More articles by this author , John FitzgeraldJohn Fitzgerald More articles by this author , Robert SvatekRobert Svatek More articles by this author , and Dipen ParekhDipen Parekh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.558AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic Assisted Laparoscopic Radical Cystectomy (RARC) has been reported with potential benefits compared to the traditional Open Radical Cystectomy (ORC), though to date no study has compared health related quality of life (HRQOL) outcomes between ORC and RARC in a prospective randomized fashion. METHODS Prospective Randomized Clinical trial evaluating the HRQOL using the FACT-VCI for ORC versus RARC in consecutive patients from July 2009 to June 2011. RESULTS To date 47 patients had met inclusion criteria, with 40 patients being randomized for analysis. The groups consisted of 20 ORC and 20 RARC, each similar with regards to age, sex, race, BMI, comorbidities (ASA), previous abdominal procedures, type of urinary diversion, perioperative chemotherapy, length of stay, and final pathologic stage. We administered the FACT-VCI HRQOL preoperatively and then at 3, 6, 9, and 12 months postoperatively. We noted a return to baseline at 3 months postoperatively in all measured domains with no statistically significant difference between the robotic and open groups. CONCLUSIONS There are no differences in the HRQOL outcomes between ORC and RARC with return of quality of life to baseline 3 months after radical cystectomy. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e145-e146 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Jamie Messer More articles by this author John Fitzgerald More articles by this author Robert Svatek More articles by this author Dipen Parekh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V10-10 THE ROLE OF ROBOTIC CYSTO-PROSTATECTOMY WITH BILATERAL NERVE AND APEX PRESERVATION IN YOUNG PATIENTS WITH BLADDER CANCER

INTRODUCTION AND OBJECTIVES: To present our surgical technique in patients who underwent Total Intracorporeal Robot assisted Laparoscopic Pitcher Pot Ileal Neobladder (TIRLPIN) for muscle invasive transitional cell carcinoma of bladder. METHODS: 101 patients underwent Robotic Radical Cystectomies from February 2011 to August 2013. Ileal Conduit urinary diversion were done extracorporeally in 44 patients and Neobladders were done extracorporeally in 50 patients. Total Intracorporeal Robot assisted Laparoscopic Ileal conduit was performed in 4 patients and Total Intracorporeal Robot assisted Laparoscopic Pitcher pot Ileal Neobladder(TIRLPIN) were done in 3 patients. [Pitcher pot Ileal Neobladder is a modification of Studer Neobladder which is ileal neobladder in spherical configuration with ileal neourethra (giving the shape of an inverted Indian earthenware container called a ‘pitcher pot’) to circumvent the problem of short mesentery and construct a low-pressure spherical ileal neobladder]. Three patients who underwent robot assisted laparoscopic radical cystectomy extended pelvic lymph node dissection, transposition of left ureter to the right, Pitcher pot ileal neobladder including isolation of 55 cm of ileal loop and bilateral stented uretero-ileal anastomosis in end to side fashion were all performed intracorporeally using the da Vinci Surgical Robot and finally specimen was retrieved. We demonstrate our technique of TIRLPIN with da Vinci Robotic system. RESULTS: TIRLPIN technically successful in all the 3 patients. Median patient age, body mass index, estimated blood loss were 65 years(range 56-67), 26.2(23.5-27), 300 ml(280-320ml, respectively. Average operative time was 600 minutes (540-720 min). Average time for the cystectomy was 135 minutes. Mean time to liquid diet was 3.3 days and the stents were removed on seventh day. Perurethral catheter was removed on tenth day in neobladder patients. Median post operative hospital stay was 16 days(12-18 days). 30-day and 90-day complications were Clavien grade 1-2 (n1⁄4 3 and 2), clavien grade 3-5 (n1⁄4 0 and 0). All patients received Total parental nutrition. One patient had high persistent drain output which resolved after keeping perurethral catheter for extra 1 week. All patients have completed 3 months of follow up. CONCLUSIONS: TIRLPIN for neobladder formation is technically feasible. The robotic system aids in replicating open procedure of reservoir configuration precisely, with reduced perioperative morbidity, minimal blood loss and good cosmetic results.

V10-09 SURGICAL TECHNIQUE OF TOTAL INTRACORPOREAL ROBOT ASSISTED LAPAROSCOPIC PITCHER POT ILEAL NEOBLADDER FOR MUSCLE INVASIVE TRANSITIONAL CELL CARCINOMA OF BLADDER

INTRODUCTION AND OBJECTIVES: To present our surgical technique in patients who underwent Total Intracorporeal Robot assisted Laparoscopic Pitcher Pot Ileal Neobladder (TIRLPIN) for muscle invasive transitional cell carcinoma of bladder. METHODS: 101 patients underwent Robotic Radical Cystectomies from February 2011 to August 2013. Ileal Conduit urinary diversion were done extracorporeally in 44 patients and Neobladders were done extracorporeally in 50 patients. Total Intracorporeal Robot assisted Laparoscopic Ileal conduit was performed in 4 patients and Total Intracorporeal Robot assisted Laparoscopic Pitcher pot Ileal Neobladder(TIRLPIN) were done in 3 patients. [Pitcher pot Ileal Neobladder is a modification of Studer Neobladder which is ileal neobladder in spherical configuration with ileal neourethra (giving the shape of an inverted Indian earthenware container called a ‘pitcher pot’) to circumvent the problem of short mesentery and construct a low-pressure spherical ileal neobladder]. Three patients who underwent robot assisted laparoscopic radical cystectomy extended pelvic lymph node dissection, transposition of left ureter to the right, Pitcher pot ileal neobladder including isolation of 55 cm of ileal loop and bilateral stented uretero-ileal anastomosis in end to side fashion were all performed intracorporeally using the da Vinci Surgical Robot and finally specimen was retrieved. We demonstrate our technique of TIRLPIN with da Vinci Robotic system. RESULTS: TIRLPIN technically successful in all the 3 patients. Median patient age, body mass index, estimated blood loss were 65 years(range 56-67), 26.2(23.5-27), 300 ml(280-320ml, respectively. Average operative time was 600 minutes (540-720 min). Average time for the cystectomy was 135 minutes. Mean time to liquid diet was 3.3 days and the stents were removed on seventh day. Perurethral catheter was removed on tenth day in neobladder patients. Median post operative hospital stay was 16 days(12-18 days). 30-day and 90-day complications were Clavien grade 1-2 (n1⁄4 3 and 2), clavien grade 3-5 (n1⁄4 0 and 0). All patients received Total parental nutrition. One patient had high persistent drain output which resolved after keeping perurethral catheter for extra 1 week. All patients have completed 3 months of follow up. CONCLUSIONS: TIRLPIN for neobladder formation is technically feasible. The robotic system aids in replicating open procedure of reservoir configuration precisely, with reduced perioperative morbidity, minimal blood loss and good cosmetic results.

30-Day Hospital Readmission after Robotic Partial Nephrectomy—Are We Prepared for Medicare Readmission Reduction Program?

After CMS introduced the concept of the Hospital Readmissions Reduction Program, hospitals and health care centers became financially penalized for exceeding specific readmission rates. We retrospectively reviewed our institutional review board approved database of patients undergoing robotic partial nephrectomy at our institution and included in our analysis patients who were readmitted to any hospital as an inpatient stay within 30 days from discharge home after robotic partial nephrectomy. From March 2006 to March 2013 a total of 627 patients underwent robotic partial nephrectomy at our center and 28 (4.46%) were readmitted within 30 days of surgery. Postoperative bleeding was responsible for 8 (28.5%) readmissions. Pulmonary embolism was reported in 3 cases and retroperitoneal abscess was diagnosed in 2. Urinary leak requiring surgical intervention developed in 2 patients, pneumonia was diagnosed in 2 and 2 patients were readmitted for chest pain. Overall 9 (32.1%) patients presented with major complications requiring intervention. On multivariable analysis Charlson comorbidity index score was the only factor significantly associated with a higher 30-day readmission rate (p = 0.03). If the Charlson score was 5 or greater the chance of hospital readmission would be 2.7 times higher. Increased comorbidity, specifically a Charlson score of 5 or greater, was the only significant predictor of a higher incidence of 30-day readmission. This information can be useful in counseling patients regarding robotic partial nephrectomy and in determining baseline rates if CMS expands the number of conditions they evaluate for excess 30-day readmissions.

Early and Late Complications of Robot-Assisted Radical Cystectomy: A Standardized Analysis by Urinary Diversion Type

Minimally invasive surgical treatment for bladder cancer has gained popularity but standardized data on complications are lacking. Urinary diversion type contributes to complications and to our knowledge diversion types after minimally invasive cystectomy have not yet been compared. We evaluated perioperative complications stratified by urinary diversion type in patients treated with robot-assisted radical cystectomy. We analyzed the records of 209 consecutive patients who underwent robot-assisted radical cystectomy at our institution from 2003 to 2012 with respect to perioperative complications, including severity, time period (early and late) and diversion type. All complications were reviewed by academic urologists. Urinary diversion was also done. As outcome measurements and statistical analysis, univariate and multivariate logistic regression models were used to determine predictors of various complications. The American Society of Anesthesiologists(®) (ASA) score was 3 or greater in 80% of patients and continent diversion was performed in 68%. Median followup was 35 months. Within 90 days 77.5% of patients experienced any complication and 32% experienced a major complication. The 90-day mortality rate was 5.3%. Most complications were gastrointestinal, infectious and hematological. On multivariate analysis patients with ileal conduit diversion had a decreased likelihood of complications compared to patients with Indiana pouch and orthotopic bladder substitute diversion despite the selection of a more comorbid population for conduit diversion. Continent diversion was associated with a higher likelihood of urinary tract infection. Our results are comparable to those of previously reported open and minimally invasive cystectomy series. Open or minimally invasive cystectomy is a complex, morbid procedure. Urinary diversion is a significant contributor to complications, as is patient comorbidity. Although patients with an ileal conduit had more comorbidities, they experienced fewer complications than those with an orthotopic bladder substitute or Indiana pouch diversion.

Extended Pelvic Lymph Node Dissection in Patients Undergoing Robot-Assisted Laparoscopic Radical Cystectomy

Introduction: Extended pelvic lymph node dissection (PLND) during radical cystectomy may be important not only for improved staging, but also for a survival benefit. To assess the utility of robotic surgery in lymph node dissection, we evaluated the feasibility, safety, and efficacy of extended PLND in patients undergoing robot-assisted laparoscopic radical cystectomy (RARC) for urothelial carcinoma of the bladder. Materials and Methods: Thirty-six patients with invasive urothelial carcinoma of the bladder underwent extended PLND during RARC by a single surgeon between March 2011 and December 2012. Preoperative, intraoperative, and postoperative parameters were recorded and analyzed. Surgical Technique: Extended PLND was performed following radical cystectomy incorporating a template dissection using as boundaries, the node of Cloquet distally, genitofemoral nerve anteriorly, iliacus muscle laterally, hypogastric vessels inferiorly, and aortic bifurcation proximally, including the presacral region. In select cases, when suspicious nodes at the common iliac artery were encountered, para-aortic and precaval lymph nodes to the level of the inferior mesenteric artery were incorporated. Results: The median age at surgery was 70 years (interquartile range [IQR]: 63–77), with median body mass index at 25 kg/m2 (IQR: 23–27). The median estimated blood loss was 200 mL (IQR: 100–400) and the transfusion rate was 11% for the entire surgery. The median length of hospital stay was 9 days (IQR: 7–13). No complications attributed to the node dissection occurred, including obturator nerve injuries or clinically significant lymphoceles. A median number of 31 nodes (IQR: 24–40) were harvested in 36 patients. Of these patients, there were 24 (67%) who were node-negative and 12 (33%) who were node-positive. There were 17 (47%) patients with T3/T4 pathologic stage, of which, nine were node-positive. The node-positive rates were higher in T3/T4 stage patients (p = 0.018). At a median follow-up time of 16 months (IQR: 11–21), 25 patients were alive and disease free, four were alive with metastasis, four died of metastatic disease, and three died of unrelated causes. All eight cases of recurrence had positive lymph nodes. Conclusions: Extended PLND during RARC is technically feasible and safe. As a surrogate to long-term survival, comparable lymph node yields may be achieved with a thorough extended lymph node dissection in patients undergoing RARC. No competing financial interests exist. Runtime of video: 8 mins 40 secs

Robotic and Laparoscopic Radical Cystectomy for Bladder Cancer: Long-term Oncologic Outcomes

BackgroundExtended oncologic outcomes after minimally invasive cystectomy have not been previously reported. ObjectiveTo report outcomes of robot-assisted radical cystectomy (RARC) and laparoscopic radical cystectomy (LRC) for bladder cancer (BCa) at up to 12-yr follow-up. Design, setting, and participantsAll 121 patients undergoing RARC or LRC for BCa between December 1999 and September 2008 at a tertiary referral center were retrospectively evaluated from a prospectively maintained database. InterventionRARC or LRC. Outcome measurements and statistical analysisPrimary end points were overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) calculated using Kaplan-Meier curves. Secondary end points were survival analysis by number of lymph nodes (LNs) and type of procedure. Surgical outcomes, including complications, were analyzed. Results and limitationsMost tumors were muscle invasive (≥pT2; n=81; 67%) urothelial carcinomas (n=102; 84%). Extended LN dissection was performed in 98 patients (81%), with a median of 14 nodes removed (interquartile range [IQR]: 8–18). Twenty-four patients (20%) had node-positive disease (N1: 10 [8%]; N2: 14 [12%]). Eight patients (6.6%) had positive soft tissue margins. Median follow-up was 5.5 yr (mean: 5.9; IQR: 4.2–8.2; range: 0.13–12.1). At last follow-up, 58 patients (48%) had no evidence of disease, 3 (2%) were alive with recurrence, 59 (49%) had died, and status was unknown in 1. Twenty-eight patients (23%) died from cancer-specific causes, 20 (17%) from unrelated causes, and 11 (9%) from unknown causes. The 10-yr actuarial OS, CSS, and RFS rates were 35%, 63%, and 54%, respectively. At last follow-up, OS for pT0, pTis/a, pT1, pT2, and pT3 versus pT4 was 67%, 73%, 53%, 50%, and 16% versus 0%, respectively (p=0.02). At last follow-up, CSS for pT0, pTis/a, pT1, pT2, and pT3 versus pT4 was 100%, 91%, 74%, 77%, and 56% versus 0%, respectively (p=0.03). ConclusionsThe longest oncologic outcomes following RARC and LRC for BCa reported demonstrates results similar to those reported for open RC. Continued analysis and direct randomized comparison between techniques is necessary.

Robot‐assisted laparoscopic vs open radical cystectomy: comparison of complications and perioperative oncological outcomes in 200 patients

To compare perioperative morbidity and oncological outcomes of robot-assisted laparoscopic radical cystectomy (RARC) to open RC (ORC) at a single institution. A retrospective analysis was performed on a consecutive series of patients undergoing RC (100 RARC and 100 ORC) at Wake Forest University with curative intent from 2006 until 2010. Complication data using the Clavien system were collected for 90 days postoperatively. Complications and other perioperative outcomes were compared between patient groups. Patients in both groups had comparable preoperative characteristics. The overall and major complication (Clavien ≥ 3) rates were lower for RARC patients at 35 vs 57% (P = 0.001) and 10 vs 22% (P = 0.019), respectively. There were no significant differences between groups for pathological outcomes, including stage, number of nodes harvested or positive margin rates. Our data suggest that patients undergoing RARC have perioperative oncological outcomes comparable with ORC, with fewer overall or major complications. Definitive claims about comparative outcomes with RARC require results from larger, randomised controlled trials.