Robotic Surgeons Research Articles

Transthoracic Aortic Clamp Technique for Port-Only Endoscopic Robotic Mitral Surgery.

Many robotic mitral surgeons utilize right thoracotomy with transthoracic clamping of the aorta, while a smaller number employ a port-only endoscopic approach with endoaortic balloon occlusion of the aorta. We present our technique for a port-only endoscopic robotic approach with transthoracic clamping. From July 2019 through December 2022, 133 patients underwent port-only endoscopic robotic mitral surgery with transthoracic clamp aortic occlusion and antegrade cardioplegia. Perfusion was through the femoral artery in 101 patients (76%) and axillary in 32 patients (24%). Clamp technique involved placing the clamp at the mid-ascending aorta, dynamic valve testing to 90 mm aortic root pressure, and closure of the cardioplegia cannula site prior to clamp removal. Indications for clamp utilization over balloon occlusion included both balloon supply issues and aortoiliac anatomy. Mitral repair was performed in 122 patients (92.7%) and mitral valve replacement in 11 patients (8.3%). Mean aortic occlusion time was 92 ± 21.4 min. Mean time from left atrial closure to clamp removal was 8.7 (7.2 to 12.8) min. There were no injuries to the aorta or surrounding structures, mortality, strokes, or renal failure. For robotic teams with endoaortic balloon capability, this technique may be useful in certain patients with aorto-iliac pathology or limited femoral artery access. Alternatively, robotic teams who employ transthoracic aortic clamping through a thoracotomy may find this technique useful to transition to a port-only endoscopic approach.

Muscle fatigue and physical discomfort reported by surgeons performing robotic-assisted surgery: a multinational survey.

Robotic surgery has revolutionized surgical procedures and has provided many advantages over traditional laparoscopic and open surgeries. Despite the benefits, there are concerns about the physical discomfort and injuries that may be experienced by surgeons during robotic surgeries. This study aimed to identify the most common muscle groups implicated in robotic surgeons' physical pain and discomfort. A questionnaire was created and sent to 1000 robotic surgeons worldwide, with a response rate of 30.9%. The questionnaire consisted of thirty-seven multiple-choice questions, three short answer questions, and one multiple-option question pertaining to the surgeon's workload as well as their level of discomfort while and after performing surgery. The primary endpoint was to identify the most common muscle groups implicated in robotic surgeons' physical pain and discomfort. Secondary endpoints were to highlight any correlation between age group, BMI, hours of operation, workout regimen, and significant pain levels. The results showed that the most common muscle groups implicated in physical pain and discomfort were the neck, shoulders, and back, with many of the surgeons attributing their muscular fatigue and discomfort to the ergonomic design of the surgeon console. Despite the level of surgeon comfort the robotic console provides when compared to other conventional forms of surgery, the findings suggest the need for better ergonomic practices during robotic surgeries to minimize physical discomfort and injuries for surgeons.

Avascular midline oropharyngeal anatomy allows for expanded indications for transoral robotic surgery in pediatric patients.

Transoral robotic surgery (TORS) in children is in its infancy, and indications have been primarily limited to lingual tonsillar hypertrophy and superficial mucosal lesions. However, the relatively avascular channel of the midline posterior tongue, vallecula, and posterior hyoid space provides a safe plane of dissection for deep lesions of the tongue and access to structures in the anterior neck. As robotic surgeons gain experience, application of this technology will continue to grow. The method is retrospective case series. We present seven patients who had either a primary (n = 3) or recurrent (n = 4) lingual thyroglossal duct cyst (TGDC) and underwent TORS excision. Four of the seven patients also underwent transoral resection of the central portion of the hyoid bone, while three had central hyoid resection during prior surgery. Two minor complications occurred with no evidence of lesion recurrence after mean follow-up of 19.7 mo. The midline avascular channel of the tongue allows for relatively bloodless surgical access to pathologies of the midline base of tongue and anterior neck. Lingual thyroglossal duct cysts can safely be removed via aTORS approach with evidence of limited recurrence. Robotic technology can provide safe and effective surgical alternatives for children with a variety of pathologies, and we aim to promote the widespread adoption of TORS in pediatric head and neck surgery by sharing our knowledge and clinical experience. Further study and publication are needed to establish safety and efficacy.

Intersphincteric resection and coloanal anastomosis in the treatment of distal rectal cancers

ObjectiveIn the evolving era of minimal access surgery, low rectal cancers still pose a challenge to laparoscopic or robotic surgeons. Hence, at our institute we intended to demonstrate the oncological efficacy of intersphincteric resection and coloanal anastomosis in the treatment of distal rectal cancers, performing the abdominal part of the procedure which includes rectal mobilization, laparoscopically. MethodsFrom February 2017 to March 2021, 125 patients who had undergone intersphincteric resection and coloanal anastomosis via the perineal approach at Galaxy Care Laparoscopic Institute, Pune, were included in this study. Transabdominal mobilization of the rectum was performed laparoscopically. All patients had a diversion ileostomy and a pelvic drain. Patients were followed-up for a period of 18 months post-surgery. Data on clinical and oncological outcomes were collected and analysed. The pre-operative and post-operative Wexner incontinence scores were compared. ResultsThe mean time taken for surgery was 181.57 ± 30.00 min. The mean blood loss was 119.76 ± 42.53 mL. Most patients (103, 82.4%) had their tumour at a distance of 1–2 cm from the anal verge. A loco-regional recurrence rate of 12.8% (16/125) was noted in our study. For the post-surgery Wexner score, 74.4% of patients (93/125) had a score of 5 or less, depicting that three-quarters of the study population had satisfactory continence. Overall, 81.6% of patients were satisfied with the functional results of surgery. ConclusionIntersphincteric resection and coloanal anastomosis, with a 12.8% recurrence rate, can now be considered an oncological and technically feasible procedure with sphincter salvage and good continence.

V05-12 ANTERIOR RETROPERITONEAL APPROACH TO THE SINGLE PORT PARTIAL NEPHRECTOMY

You have accessJournal of UrologyCME1 Apr 2023V05-12 ANTERIOR RETROPERITONEAL APPROACH TO THE SINGLE PORT PARTIAL NEPHRECTOMY Grace Chen and Simone Crivellaro Grace ChenGrace Chen More articles by this author and Simone CrivellaroSimone Crivellaro More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003263.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Since the Food and Drug Administration’s (FDA) approval of the da Vinci Single-Port (SP) robotic platform in 2018, a wealth of new surgical techniques have been described that capitalize on the SP platform’s proficiency in small spaces. A rarely described technique even among robotic surgeons is the anterior retroperitoneal approach. To our knowledge, this is the first description of this approach utilizing the SP platform in the literature. Our objective is to describe the technique used at our institution for the anterior retroperitoneal single port partial nephrectomy. METHODS: This video abstract uses intraoperative recordings from one patient who underwent a SP partial nephrectomy at our institution. The clinical techniques are described in detail following detailed discussion with an experience robotic surgeon (SC). No pathologic or short-term outcomes were available. RESULTS: Retroperitoneal access was successfully obtained via an anterior incision for a 3.7 cm interpolar mass. The mass was successfully treated without need for conversion to multi-port or open approaches. Total operative time was 192 minutes. Total estimated blood loss (EBL) was 20 cc. The total hospital length of stay (LOS) was 8 hours. The patient was successfully discharged home with a non-narcotic pain control plan. CONCLUSIONS: The anterior retroperitoneal approach to SP robotic partial nephrectomy is safe and feasible. Theoretical advantages of this approach include increased efficiency and decreased positional injuries due to the ability to perform surgery in the supine position, less bowel manipulation, and potentially decreased opioid requirements. Further outcomes data is anticipated. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e428 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Grace Chen More articles by this author Simone Crivellaro More articles by this author Expand All Advertisement PDF downloadLoading ...

V03-09 MANAGEMENT OF INTRAOPERATIVE VASCULAR INJURIES IN UROLOGIC SINGLE-PORT OR MULTI-PORT ROBOTIC SURGERY

You have accessJournal of UrologyCME1 Apr 2023V03-09 MANAGEMENT OF INTRAOPERATIVE VASCULAR INJURIES IN UROLOGIC SINGLE-PORT OR MULTI-PORT ROBOTIC SURGERY Anh Nguyen, David Ali, Benjamin Rudnick, Rogerio Huang, Mubashir Shabil Billah, and Mutahar Ahmed Anh NguyenAnh Nguyen More articles by this author , David AliDavid Ali More articles by this author , Benjamin RudnickBenjamin Rudnick More articles by this author , Rogerio HuangRogerio Huang More articles by this author , Mubashir Shabil BillahMubashir Shabil Billah More articles by this author , and Mutahar AhmedMutahar Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There are many challenges to managing vascular injuries during robotic urologic surgeries. These include limited exposure due to the small field, inability to quickly expand the surgical field with retractors and additional personnel, inability manually palpate or apply manual pressure over a broad area, and reliance on a limited array of robotic instruments. Other challenges include the limited field of vision of the robotic camera, as well as reliance on insufflation to maintain adequate visualization. Consultant surgeons may not have significant experience with using the robot. These all can translate into longer operative times for repair of vascular injuries with resultant blood loss. We sought to share insights on how a robotic surgeon may handle repairing a vascular injury. METHODS: Three robotic multi- and single-port operative cases with vascular injuries were examined. Operative strategy was analyzed and discussed. RESULTS: A single-port robotic nephroureterctomy was done on a 68 year-old female with past history of endometrial cancer, hysterectomy with lymph node dissection, and radiation to the pelvis. A common iliac vein injury was incurred during dissection of the distal ureter and was repaired using robotic 4th arm to clamp the injured vessel, strategic use of ROSI suction, and non-absorbable 4-0 suture. A multi-port robotic radical prostatectomy was done on a 63 year-old male with history of Gleason 4+3 prostate cancer with inadvertent injury of the external iliac artery. A combination of robotic bulldog clamps, assistant suction and non-absorbable 4-0 suture was used to successfully repair the injury. Lastly, a multi-port robotic adrenalectomy was done for a 48 year-old female with a 6.5 cm adrenal mass with invasion into the IVC. Repair of the IVC was done with a combination of 4th arm and bulldog clamps, vessel loop traction, and non-absorbable 4-0 suture. CONCLUSIONS: Strategies to robotically repair inadvertent vascular injuries during urologic surgery require strategic use of the 4th robotic arm, assistant- or robotically-applied clamps, and assistant instruments to free up working arms. Non-absorbable suture should be readily available. Closure of large blood vessels require releasing clamps momentarily before closure to avoid air embolus. Maximal visualization can be achieved using the zoom features of the robotic camera and its ability to discriminate fine detail. Maintaining composure with frequent and adequate communication with anesthesia and intensive care teams is vital in safely managing vascular injuries. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e248 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anh Nguyen More articles by this author David Ali More articles by this author Benjamin Rudnick More articles by this author Rogerio Huang More articles by this author Mubashir Shabil Billah More articles by this author Mutahar Ahmed More articles by this author Expand All Advertisement PDF downloadLoading ...

V06-04 ROBOTIC-ASSISTED INTRACORPOREAL NEOBLADDER RECONSTRUCTION WITH Y-SHAPED RESERVOIR: VIDEO DESCRIPTION AND CLINICAL OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023V06-04 ROBOTIC-ASSISTED INTRACORPOREAL NEOBLADDER RECONSTRUCTION WITH Y-SHAPED RESERVOIR: VIDEO DESCRIPTION AND CLINICAL OUTCOMES Bernardo Rocco, Simone Assumma, Tommaso Calcagnile, Filippo Turri, Mattia Sangalli, Luca Sarchi, Giulia Garelli, Daniele Stroppa, Enrico Panio, Giorgio Bozzini, Salvatore Micali, Paolo Marcangeli, Angelica Grasso, Matteo Maggioni, Alberto Del Nero, Paolo Dell'Orto, and Maria Sighinolfi Bernardo RoccoBernardo Rocco More articles by this author , Simone AssummaSimone Assumma More articles by this author , Tommaso CalcagnileTommaso Calcagnile More articles by this author , Filippo TurriFilippo Turri More articles by this author , Mattia SangalliMattia Sangalli More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Giulia GarelliGiulia Garelli More articles by this author , Daniele StroppaDaniele Stroppa More articles by this author , Enrico PanioEnrico Panio More articles by this author , Giorgio BozziniGiorgio Bozzini More articles by this author , Salvatore MicaliSalvatore Micali More articles by this author , Paolo MarcangeliPaolo Marcangeli More articles by this author , Angelica GrassoAngelica Grasso More articles by this author , Matteo MaggioniMatteo Maggioni More articles by this author , Alberto Del NeroAlberto Del Nero More articles by this author , Paolo Dell'OrtoPaolo Dell'Orto More articles by this author , and Maria SighinolfiMaria Sighinolfi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003274.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: One of the hardest surgical challenges for robotic surgeon is intracorporeal neobladder reconstruction during robotic radical cystectomy (RARC). In the present video, we illustrate a step-by-step description of the technique and the clinical outcomes from a single center series. METHODS: Overall, 40 RARC were performed between July 2021 and October 2022: 20/40 patients underwent intracorporeal neobladder reconstruction and were enrolled in the study. When RARC is completed, a 40-50 cm ileal segment is isolated and the part with adequate mesenteric length is approximated to the urethral stump. A modified posterior reconstruction is conducted. Anastomosis with a barbed suture is finalized. Ileal segments at each side are isolated using robotic staplers and ileal-ileal anastomosis is accomplished. Ileum's reverse tubular U-segment is detubularized to create the neobladder. Posterior plane is first sutured; then, the orhotopic reservoir with two lateral limbs is created. After negative leakage test, a direct uretero-neobladder anastomosis of each spatulated ureter is performed in the dorsal part of the limbs. Ureteral stents are placed and brought out through the abdominal wall. Anterior plate is finally sutured. RESULTS: Mean age was 64.5 years (48-75). Seventeen out of 20 patients were males; 3 were females. One non-surgical intra-operative complication (myocardial infarction requiring an acceleration of operative time) was recorded. During post-op course, two cases of urinary leakage at the neovescical-urethral anastomosis were evident and required prolonged catheterization. Mean length of stay was 17 days (12-27), excluding a single case of prolonged hospitalization due to C. Albicans superinfection. The 30-day readmission rate was 20% (4/20) due to febrile urinary tract infections; 90-day readmission rate was just 5% (1 symptomatic lymphocele requiring percutaneous drainage). Most male patients (14/17) reported daytime continence with insignificant post-voided residual. Between those patients in which nerve-sparing approach was pursued – and have more than 90 days of follow up – 3/5 referred potency. Regarding female patients, incomplete voiding is reported in a case and urinary incontinence (2 pads/day) in another. CONCLUSIONS: Intracorporeal neobladder reconstruction is a complex procedure even for expert robotic surgeons. Nevertheless, the standardization of the surgical approach – as displayed in the video – facilitates a rapid implementation of the procedure with positive surgical and clinical outcomes. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e509 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bernardo Rocco More articles by this author Simone Assumma More articles by this author Tommaso Calcagnile More articles by this author Filippo Turri More articles by this author Mattia Sangalli More articles by this author Luca Sarchi More articles by this author Giulia Garelli More articles by this author Daniele Stroppa More articles by this author Enrico Panio More articles by this author Giorgio Bozzini More articles by this author Salvatore Micali More articles by this author Paolo Marcangeli More articles by this author Angelica Grasso More articles by this author Matteo Maggioni More articles by this author Alberto Del Nero More articles by this author Paolo Dell'Orto More articles by this author Maria Sighinolfi More articles by this author Expand All Advertisement PDF downloadLoading ...

V09-05 ROBOTIC-ASSISTED VAGINOPLASTY WITH PERITONEAL COVERAGE (COMPLETE APICAL GRAFT CLOSURE VS. PERITONEAL CAP)

You have accessJournal of UrologyCME1 Apr 2023V09-05 ROBOTIC-ASSISTED VAGINOPLASTY WITH PERITONEAL COVERAGE (COMPLETE APICAL GRAFT CLOSURE VS. PERITONEAL CAP) Arman Walia, Vi Nguyen, Aditya Bagrodia, and Jennifer Anger Arman WaliaArman Walia More articles by this author , Vi NguyenVi Nguyen More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , and Jennifer AngerJennifer Anger More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile inversion vaginoplasty is a common technique for feminizing gender-affirming surgery in which a vaginal canal can be created from full thickness scrotal skin graft. Based on surgeon preference or when scrotal skin is limited, the Davydov technique described for patients with vaginal agenesis can be used (Zhao et al). In this approach, the proximal canal is formed from peritoneum as a peritoneal cap. However, a peritoneal cap may not necessary in those with adequate graft length. Here we demonstrate a modified Davydov technique is which the apex of the vaginal canal is closed and peritoneal flaps are utilized for coverage and blood supply only, rather than inclusion as the neovaginal apex. METHODS: We utilized a standard pelvic robotic port placement using the Da Vinci Xi. Side docking allows for perineal dissection and penile disassembly. Posterior dissection is performed similar to robotic prostatectomy. The peritoneum is incised and Denonvillier’s followed. The perineal surgeon directs the robotic surgeon in avoiding the rectum. Under vision from above the perineal surgeon enters the dissected space. With guidance from below, the robotic surgeon separates the lateral levator muscle until the opening is calibrated to vaginal stent diameter. Vaginal packing can be placed to facilitate remaining perineal work. The lateral peritoneal flaps are created by incising peritoneum over the external iliac artery distally. Flap length is assessed to avoid constriction over the sigmoid, and further released as needed. After confirming adequate length, the canal is delivered from below. The apex can be closed prior to delivery or robotically. The anterior peritoneal flap is harvested by continuing the lateral dissections in an inverted "U". The lateral flaps are then secured to the canal with barbed suture. Depending on patient anatomy, the anterior flap can be rotated for coverage or simply advanced posteriorly. The anterior and posterior peritoneal flaps are then approximated over the canal apex to provide blood supply to the graft. RESULTS: The above technique has been applied to our last 5 penile inversion vaginoplasty patients. Each had an unremarkable postoperative recovery and is doing well at follow up. CONCLUSIONS: Gender-affirming surgery is a growing field with evolving techniques. A robotic-assisted approach provides additional visibility and maneuverability. A modified Davydov technique for peritoneal coverage can be added to our surgical repertoire for patients with adequate canal length so that the vaginal graft can be fully closed at the apex. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e838 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arman Walia More articles by this author Vi Nguyen More articles by this author Aditya Bagrodia More articles by this author Jennifer Anger More articles by this author Expand All Advertisement PDF downloadLoading ...

PD31-07 PATIENT REPORTED OUTCOMES AFTER ROBOTIC ASSISTED LAPAROSCOPIC EXTRAVASCULAR RENAL VEIN STENT PLACEMENT FOR NUTCRACKER SYNDROME

You have accessJournal of UrologyCME1 Apr 2023PD31-07 PATIENT REPORTED OUTCOMES AFTER ROBOTIC ASSISTED LAPAROSCOPIC EXTRAVASCULAR RENAL VEIN STENT PLACEMENT FOR NUTCRACKER SYNDROME Jacques Farhi, Hal Kominsky, Mohannad Awad, and Jeffrey Cadeddu Jacques FarhiJacques Farhi More articles by this author , Hal KominskyHal Kominsky More articles by this author , Mohannad AwadMohannad Awad More articles by this author , and Jeffrey CadedduJeffrey Cadeddu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003324.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nutcracker phenomenon is the compression of the left renal vein between the superior mesenteric artery (SMA) and the abdominal aorta. Nutcracker syndrome refers to the presence of nutcracker phenomenon with symptoms including hematuria, intermittent left flank pain, early satiety, nausea, vomiting, pelvic congestion syndrome, and dyspareunia. Treatment of nutcracker syndrome includes weight gain, vascular transposition, renal autotransplant, nephrectomy, endovascular renal vein stent placement, or extravascular renal vein stent placement. Between 2016 and 2022, we performed 18 robotic assisted laparoscopic extravascular renal vein stent placement. We sought to assess patient reported outcomes of robotic assisted laparoscopic extravascular renal vein stent placement by a high-volume robotic surgeon at a single institution. METHODS: We performed a single-center retrospective review of 18 patients with a minimum 3 month follow up. Symptoms were assessed utilizing a questionnaire conducted with a five-point Likert scale at 3 months. Five on the Likert scale was severe while a one was none. Primary study outcomes compared pre-operative patient reported symptom scores versus post-operative patient reported symptom scores. RESULTS: 12 out of 18 patients responded to the survey. Average age of the cohort was 36. Average BMI was 19.4. There was only one male. Mean operative time was 136 minutes and mean estimated blood loss was 12. Mean pre-operative SMA angle was 19 and mean post operative SMA angle was 36. Patients reported that flank pain, abdominal pain, nausea, headaches, back pain, pelvic pain, and early satiety improved (p<0.05) (Figure 1). 8 respondents would strongly recommend the surgery for nutcracker syndrome. CONCLUSIONS: Robotic assisted laparoscopic extravascular renal vein stent placement demonstrates an effective treatment for nutcracker syndrome. Patients reported improved symptoms at 3 months post operatively across multiple domains. Further studies need to be conducted to assess long-term durability of robotic assisted laparoscopic extravascular renal vein stent placement. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e903 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jacques Farhi More articles by this author Hal Kominsky More articles by this author Mohannad Awad More articles by this author Jeffrey Cadeddu More articles by this author Expand All Advertisement PDF downloadLoading ...

MP67-08 SURGICAL OUTCOMES OF ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH THE NOVEL "HUGO" ROBOTIC SYSTEM: INITIAL 100 CASES PERFORMED AT A TERTIARY REFERRAL ROBOTIC CENTER CENTER

You have accessJournal of UrologyCME1 Apr 2023MP67-08 SURGICAL OUTCOMES OF ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH THE NOVEL "HUGO" ROBOTIC SYSTEM: INITIAL 100 CASES PERFORMED AT A TERTIARY REFERRAL ROBOTIC CENTER CENTER Marco Paciotti, Carlo Bravi, Angelo Mottaran, Adele Piro, Luca Sarchi, Maria Peraire Lores, Eleonora Balestrazzi, Luigi Nocera, Federico Piramide, Ruben De Groote, Geert De Naeyer, Frederiek D'Hondt, and Alexandre Mottrie Marco PaciottiMarco Paciotti More articles by this author , Carlo BraviCarlo Bravi More articles by this author , Angelo MottaranAngelo Mottaran More articles by this author , Adele PiroAdele Piro More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Maria Peraire LoresMaria Peraire Lores More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Federico PiramideFederico Piramide More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , Geert De NaeyerGeert De Naeyer More articles by this author , Frederiek D'HondtFrederiek D'Hondt More articles by this author , and Alexandre MottrieAlexandre Mottrie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003330.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: HUGO Robot-Assisted Surgery (RAS) system (Medtronic©, USA) has recently received CE mark approval for urological procedures. Herein, we described clinical outcomes of the first case series of robot-assisted radical prostatectomy (RARP) with the HUGO RAS system. METHODS: We analyzed data of 107 patients who received RARP±extended pelvic lymph-node dissection (ePLND) at OLV hospital (Aalst, Belgium). All procedures were performed by experienced robotic surgeons. We described peri-, post-operative and functional outcomes. Final pathology results were available for 100 patients. Continence was defined as the use of no/one safety pad. RESULTS: Median (interquartile range [IQR]) age was 65 (60, 70) years. Median (IQR) preoperative PSA level was 7.8 (5.6, 10.2) ng/ml. A total of 36 (34%) patients had International Society of Urologic Pathology (ISUP) group 3-5 tumors on prostate biopsy. On preoperative MRI, median (IQR) prostate volume was 40 (32, 55) ml, and twenty patients (19%) had a suspicion of extra-prostatic disease. All twelve validated steps of the procedure were completed, with no need for conversion or for additional ports placement. 28 (26%) patients received an ePLND. No intraoperative complication was recorded. Median (IQR) operative and console time were 180 (140, 200) and 150 (110, 180) minutes, respectively. Median (IQR) estimated blood loss was 450 (250, 550) ml. Median (IQR) postoperative day of removal of urethral catheter was 2 (2, 2) days. After surgery, one patient experienced an acute urinary retention that was treated with re-catheterization. Two patients had a Clavien-Dindo ≥2 postoperative complications. Median (IQR) length of stay was 3 (3, 4) days. On final pathology, 42 (42%) and 28 (28%) patients had ISUP group 3-5 tumors and evidence of extraprostatic extension, respectively. A total of 8 (8%) patients had positive surgical margins. A total of 77 and 45 patients had available data on urinary continence recovery at one and three months after surgery, respectively. One month after surgery, 49/77 (64%) patients were continent, whereas 41/45 (91%) recovered urinary continence 3 months after surgery. CONCLUSIONS: In this clinical investigation, we showed that RARP performed with the novel HUGO RAS system achieves optimal oncologic and functional outcomes. Further, multi-centric data are awaited to confirm these findings at longer follow-up, with respect to biochemical recurrence and erectile function recovery after surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e946 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marco Paciotti More articles by this author Carlo Bravi More articles by this author Angelo Mottaran More articles by this author Adele Piro More articles by this author Luca Sarchi More articles by this author Maria Peraire Lores More articles by this author Eleonora Balestrazzi More articles by this author Luigi Nocera More articles by this author Federico Piramide More articles by this author Ruben De Groote More articles by this author Geert De Naeyer More articles by this author Frederiek D'Hondt More articles by this author Alexandre Mottrie More articles by this author Expand All Advertisement PDF downloadLoading ...

PD27-06 SINGLE-PORT ROBOTIC RADICAL PROSTATECTOMY IN OVER 1,100 CONSECUTIVE PATIENTS FROM THE MULTI-INSTITUTIONAL SPARC COLLABORATION

You have accessJournal of UrologyCME1 Apr 2023PD27-06 SINGLE-PORT ROBOTIC RADICAL PROSTATECTOMY IN OVER 1,100 CONSECUTIVE PATIENTS FROM THE MULTI-INSTITUTIONAL SPARC COLLABORATION Ethan Ferguson, Roxana Ramos, Graham Hale, Jennifer Nguyen, Marcio Moschovas, Samantha Wilder, Kennedy Okhawere, Ruth Sanchez De La Rosa, Alp Tuna Beksac, Indu Saini, James Peabody, Ketan K. Badani, Craig Rogers, Jean Joseph, Vipul Patel, Michael Stifelman, Jeffrey Nix, Moses Kim, Mutahar Ahmed, Simone Crivellaro, and Jihad Kaouk Ethan FergusonEthan Ferguson More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Graham HaleGraham Hale More articles by this author , Jennifer NguyenJennifer Nguyen More articles by this author , Marcio MoschovasMarcio Moschovas More articles by this author , Samantha WilderSamantha Wilder More articles by this author , Kennedy OkhawereKennedy Okhawere More articles by this author , Ruth Sanchez De La RosaRuth Sanchez De La Rosa More articles by this author , Alp Tuna BeksacAlp Tuna Beksac More articles by this author , Indu SainiIndu Saini More articles by this author , James PeabodyJames Peabody More articles by this author , Ketan K. BadaniKetan K. Badani More articles by this author , Craig RogersCraig Rogers More articles by this author , Jean JosephJean Joseph More articles by this author , Vipul PatelVipul Patel More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Jeffrey NixJeffrey Nix More articles by this author , Moses KimMoses Kim More articles by this author , Mutahar AhmedMutahar Ahmed More articles by this author , Simone CrivellaroSimone Crivellaro More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003305.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical prostatectomy using the single-port (SP) robotic platform has been performed using a variety of surgical approaches. We sought to report the outcomes of a large multi-institutional series and compare techniques. METHODS: From 2/2019 to 10/2022, SP robotic radical prostatectomy was performed in 1,103 patients by experienced robotic surgeons at nine institutions from the SPARC collaboration. Perioperative data and early postoperative outcomes were collected prospectively and analyzed retrospectively. RESULTS: SP radical prostatectomy was performed using transperitoneal (TP, n=244), extraperitoneal (EP, n=712), and transvesical (TV, n=147) approaches. All procedures were completed successfully without intraoperative complications or open conversion. About 30% of all patients had a history of prior abdominal surgery, with significant differences noted based on operative technique; 50% TV, 30% EP, and 3% TP. The EP approach was associated with higher NCCN risk and biopsy Gleason scores, as well as a higher lymph node yield than in other approaches. Opioid were prescribed in 20% and pain scores at discharge were low for all patients. Significant differences were identified in postoperative parameters including the performance of lymphadenectomy, inpatient hospital stay, and foley catheter duration. The TV approach was associated with a lower rate of positive margins (18.2%) compared with EP (30.2%) and TP (30.1%). Follow up duration for the entire series was 10.8 months. CONCLUSIONS: We reported the outcomes of a large series of single-port radical prostatectomy with promising short hospital stay and pain scores. Compared with other techniques, the transvesical approach is associated with shorter length of stay, faster time to continence, and a lower rate of positive surgical margins. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e743 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ethan Ferguson More articles by this author Roxana Ramos More articles by this author Graham Hale More articles by this author Jennifer Nguyen More articles by this author Marcio Moschovas More articles by this author Samantha Wilder More articles by this author Kennedy Okhawere More articles by this author Ruth Sanchez De La Rosa More articles by this author Alp Tuna Beksac More articles by this author Indu Saini More articles by this author James Peabody More articles by this author Ketan K. Badani More articles by this author Craig Rogers More articles by this author Jean Joseph More articles by this author Vipul Patel More articles by this author Michael Stifelman More articles by this author Jeffrey Nix More articles by this author Moses Kim More articles by this author Mutahar Ahmed More articles by this author Simone Crivellaro More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...

MP80-14 EXTRAPERITONEAL SINGLE-PORT ROBOTIC RADICAL PROSTATECTOMY IN OVER 700 PATIENTS: UPDATED MULTI-INSTITUTIONAL COHORT STUDY FROM THE SPARC COLLABORATION

You have accessJournal of UrologyCME1 Apr 2023MP80-14 EXTRAPERITONEAL SINGLE-PORT ROBOTIC RADICAL PROSTATECTOMY IN OVER 700 PATIENTS: UPDATED MULTI-INSTITUTIONAL COHORT STUDY FROM THE SPARC COLLABORATION Ethan Ferguson, Jennifer L. Nguyen, Roxana Ramos, Grace Chen, Kennedy Okhawere, Samantha Wilder, Ruth Sanchez De La Rosa, Jaya Chavali, Indu Saini, James Peabody, Ketan K. Badani, Craig Rogers, Jeffrey Nix, Jean Joseph, Michael Stifelman, Simone Crivellaro, Mutahar Ahmed, Moses Kim, and Jihad Kaouk Ethan FergusonEthan Ferguson More articles by this author , Jennifer L. NguyenJennifer L. Nguyen More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Grace ChenGrace Chen More articles by this author , Kennedy OkhawereKennedy Okhawere More articles by this author , Samantha WilderSamantha Wilder More articles by this author , Ruth Sanchez De La RosaRuth Sanchez De La Rosa More articles by this author , Jaya ChavaliJaya Chavali More articles by this author , Indu SainiIndu Saini More articles by this author , James PeabodyJames Peabody More articles by this author , Ketan K. BadaniKetan K. Badani More articles by this author , Craig RogersCraig Rogers More articles by this author , Jeffrey NixJeffrey Nix More articles by this author , Jean JosephJean Joseph More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Simone CrivellaroSimone Crivellaro More articles by this author , Mutahar AhmedMutahar Ahmed More articles by this author , Moses KimMoses Kim More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003357.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: An extraperitoneal approach to single-port (SP) robot-assisted radical prostatectomy has been demonstrated with proposed benefits in decreased morbidity, single incision, and same-day discharge. We sought to determine the perioperative and early postoperative outcomes in a large, multi-institutional setting. METHODS: SP extraperitoneal radical prostatectomy was performed in 712 patients between February 2019 and October 2022. All procedures were performed by experienced robotic surgeons from eight tertiary medical centers. Data from baseline demographics, perioperative and early postoperative outcomes were collected prospectively and analyzed retrospectively RESULTS: All reported procedures were completed without open conversion, blood transfusions, or intraoperative complications. The median follow-up time was 11.7 months for the entire cohort. The median age, BMI and preoperative PSA were 64 years, 27.9kg/m2, and 6.4 ng/mL, respectively. About 30% of the patients had at least one previous abdominal surgery. On pathology, high risk disease was noted in 12% and lymph node involvement on final pathology was present in 5.8%. Extraprostatic extension was noted in 38% and positive surgical margins were present in 30.2% of cases. Lymphadenectomy was performed in 85% of patients and the median lymph node yield was 5 nodes. There were no intraoperative complications and inadvertent peritoneal entry with insufflation was rare (0.6%) and managed conservatively. Postoperative complications occurred in 11.8%. The median length of stay and foley catheter duration were 8 hours and 7 days, respectively. Postoperative recovery of continence was 69% at 3 months and 88% at 6 months. Recovery of potency was 35.6% at 6 months. CONCLUSIONS: Single-port extraperitoneal robotic radical prostatectomy is safe and feasible for management of clinically localized prostate cancer. Analysis from a large multi-institutional cohort shows promising single incision and short hospital length of stay without compromise in early functional or oncologic outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1157 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ethan Ferguson More articles by this author Jennifer L. Nguyen More articles by this author Roxana Ramos More articles by this author Grace Chen More articles by this author Kennedy Okhawere More articles by this author Samantha Wilder More articles by this author Ruth Sanchez De La Rosa More articles by this author Jaya Chavali More articles by this author Indu Saini More articles by this author James Peabody More articles by this author Ketan K. Badani More articles by this author Craig Rogers More articles by this author Jeffrey Nix More articles by this author Jean Joseph More articles by this author Michael Stifelman More articles by this author Simone Crivellaro More articles by this author Mutahar Ahmed More articles by this author Moses Kim More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...

MP46-04 THE IMPACT OF CUMULATIVE SMOKING STATUS ON PERIOPERATIVE MORBIDITY AFTER ROBOT-ASSISTED RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP46-04 THE IMPACT OF CUMULATIVE SMOKING STATUS ON PERIOPERATIVE MORBIDITY AFTER ROBOT-ASSISTED RADICAL CYSTECTOMY Pietro Piazza, Carlo Bravi, Adele Piro, Luca Sarchi, Marco Paciotti, Maria Peraire Lores, Eleonora Balestrazzi, Luigi Nocera, Melle, Belgium, Angelo Mottaran, Federico Piramide, Ruben De Groote, Geert De Naeyer, Frederiek D'hondt, Rui Farinha, Riccardo Schiavina, Eugenio Brunocilla, and Alexandre Mottrie Pietro PiazzaPietro Piazza More articles by this author , Carlo BraviCarlo Bravi More articles by this author , Adele PiroAdele Piro More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Marco PaciottiMarco Paciotti More articles by this author , Maria Peraire LoresMaria Peraire Lores More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Melle Melle More articles by this author , Belgium Belgium More articles by this author , Angelo MottaranAngelo Mottaran More articles by this author , Federico PiramideFederico Piramide More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , Geert De NaeyerGeert De Naeyer More articles by this author , Frederiek D'hondtFrederiek D'hondt More articles by this author , Rui FarinhaRui Farinha More articles by this author , Riccardo SchiavinaRiccardo Schiavina More articles by this author , Eugenio BrunocillaEugenio Brunocilla More articles by this author , and Alexandre MottrieAlexandre Mottrie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003292.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The objective of this study was to evaluate the impact of cumulative smoking exposure (pack/year) and of time since smoking cessation (>1 year) on perioperative morbidity after robot-assisted radical cystectomy (RARC) for muscle invasive bladder cancer (MIBC). METHODS: We retrospectively evaluated 328 patients treated with RARC for MIBC at OLV hospital (Aalst, Belgium) between 2015 and 2020. All procedures were performed by two highly experienced robotic surgeons. Perioperative morbidity was defined as any post-operative early (<90 days) complications and/or post-operative readmission. Multivariable logistic regressions were performed to explore the effect of smoking status (current vs. former vs. never smoker), cumulative smoking exposure (in pack-years, calculated by multiplying the number of years smoked with the average number of packs per day) and time since smoking cessation on perioperative morbidity after RARC. RESULTS: Overall, 133 (40%), 132 (40%) and 63 (20%) patients were never, former and current smokers respectively. Median age was 71 years (interquartile range [IQR]: 62, 78). No differences were recorded in terms of age, gender, and cT and cN stage (all p>0.05). No significant differences were recorded in terms of urinary diversion (UD, neobladder vs ileal conduit) or UD approach (extra-corporeal vs intra-corporeal). Current smokers had significantly longer smoking duration (43 vs. 30 years; p<0.001) and higher cumulative smoking exposure (35 vs. 30 pack/year; p=0.02) when compared with former smokers. Median time since smoking cessation for former smokers was 15 years (IQR: 8, 27). Overall, 69 (21%) patients were readmitted to the hospital without differences among the three groups. 38 current smokers (60%), 66 former smokers (50%) and 49 never smokers (37%) experienced early post-operative complications (p=0.005). 13 (24%) current smokers, 25 (17%) former smokers and 18 (13%) never smokers experienced more than one early complication. On multivariable analysis, former (odds ratio [OR]: 3.8; 95% confidence interval [CI]: 1.7, 9.3; p=0.002) and current (OR: 6.7; 95%CI: 2.8, 12; p<0.001) smokers had higher odds of perioperative morbidity as compared to patients who never smoked. CONCLUSIONS: Smoking status, time since smoking cessation and cumulative smoking exposure are significantly associated with perioperative morbidity after RARC. Further studies with longer follow-up are awaited to confirm these findings. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e631 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pietro Piazza More articles by this author Carlo Bravi More articles by this author Adele Piro More articles by this author Luca Sarchi More articles by this author Marco Paciotti More articles by this author Maria Peraire Lores More articles by this author Eleonora Balestrazzi More articles by this author Luigi Nocera More articles by this author Melle More articles by this author Belgium More articles by this author Angelo Mottaran More articles by this author Federico Piramide More articles by this author Ruben De Groote More articles by this author Geert De Naeyer More articles by this author Frederiek D'hondt More articles by this author Rui Farinha More articles by this author Riccardo Schiavina More articles by this author Eugenio Brunocilla More articles by this author Alexandre Mottrie More articles by this author Expand All Advertisement PDF downloadLoading ...

V10-04 STEP-BY-STEP DESCRIPTION OF ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH THE NOVEL HUGO RAS ROBOTIC SYSTEM USING THE “AALST TECHNIQUE”

You have accessJournal of UrologyCME1 Apr 2023V10-04 STEP-BY-STEP DESCRIPTION OF ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH THE NOVEL HUGO RAS ROBOTIC SYSTEM USING THE “AALST TECHNIQUE” Marco Paciotti, Carlo Andrea Bravi, Mottaran Angelo, Luigi Nocera, Luca Sarchi, Rui Farinha, Adele Piro, Maria Peraire Lores, Eleonora Balestrazzi, Federico Piramide, Frederiek D'Hondt, Geert De Naeyer, Aalst, Belgium, Ruben De Groote, and Alexandre Mottrie Marco PaciottiMarco Paciotti More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Mottaran AngeloMottaran Angelo More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Rui FarinhaRui Farinha More articles by this author , Adele PiroAdele Piro More articles by this author , Maria Peraire LoresMaria Peraire Lores More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Federico PiramideFederico Piramide More articles by this author , Frederiek D'HondtFrederiek D'Hondt More articles by this author , Geert De NaeyerGeert De Naeyer More articles by this author , Aalst Aalst More articles by this author , Belgium Belgium More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , and Alexandre MottrieAlexandre Mottrie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The HUGO™ RAS is a competitor for leadership in the field of robotic surgery. However, concerns remain about the ease of use of this device by new adopters. We performed the first robot-assisted radical prostatectomy (RARP) procedure in Europe with Hugo RAS. In this video, we described our surgical technique for bilateral nerve-sparing (NS) RARP performed using this novel platform. We also reported surgical setting and outcomes of our case series. METHODS: The procedure shown in the video was performed by an experienced robotic surgeon (AM) using HUGO RAS in March 2022. This robotic platform consists of four independent arm carts, novel design hand controllers and an open console. We described a RARP performed according the “Aalst technique”, including useful surgical tips. Moreover, we reported perioperative, pathological and short-term functional outcomes of consecutive patients affected by low- or intermediate-risk prostate cancer (PCa) who underwent NS RARP with HUGO RAS between February and October 2022 at our Center. RESULTS: Patients were in Trendelemburg position. One eleven-mm endoscope port was placed on the midline above the umbilicus, while other three 8 mm robotic ports were placed on a transversal line 5 cm below the optic port. Two laparoscopic ports were positioned in the right hemi-abdomen. Three arm carts were docked from the left of the operative bed, and one from the right. RARP was performed with a trans-peritoneal, anterior approach following validated metrics. Some of the specific characteristics our of technique, described in the video, are: sparing of the median umbilical ligament, postero-lateral approach to the bladder neck, antero-lateral release of the neurovascular bundles, dissection of the apex according to the “collar technique”, posterior muscolofascial reconstruction incorporated into urethrovesical anastomosis. Overall, 76 patients affected by low- or intermediate-risk PCa underwent RARP with HUGO RAS using this technique. In every case, all the steps of the procedure were completed. No intraoperative complication was recorded. Full outcomes are reported in the video. CONCLUSIONS: In this video, we described a step-by-step NS RARP performed according to our technique using the novel HUGO RAS. We provided useful tips to perform critical phases of the procedure. Experienced surgeons were able to easily perform all the surgeries with optimal perioperative, pathological, and functional outcomes. Therefore, we showed that surgical experience can be easily transferred to this novel platform. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e927 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marco Paciotti More articles by this author Carlo Andrea Bravi More articles by this author Mottaran Angelo More articles by this author Luigi Nocera More articles by this author Luca Sarchi More articles by this author Rui Farinha More articles by this author Adele Piro More articles by this author Maria Peraire Lores More articles by this author Eleonora Balestrazzi More articles by this author Federico Piramide More articles by this author Frederiek D'Hondt More articles by this author Geert De Naeyer More articles by this author Aalst More articles by this author Belgium More articles by this author Ruben De Groote More articles by this author Alexandre Mottrie More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic total mesorectal excision for rectal cancer based on the theory of fundamental use of surgical energy

Improving oncological curability and preserving urinary function must be established in robotic total mesorectal excision (TME) for rectal cancer. To achieve this, it is important to avoid nerve injury by sharp dissection of the avascular plane by the monopolar device and thermal spread. The aim of this study was to improve the robotic TME quality by focusing on the theory of fundamental use of surgical energy (FUSE) of the monopolar device and investigating the surgical procedure. In this single-center retrospective study, 26 consecutive patients who underwent robotic TME for rectal cancer at Tokyo Medical University Hospital between June 2022 and August 2022 were included. All surgeries were performed by FUSE-certified surgeons in accordance with FUSE theory, which was, thermal effect = current density (current/area) squared × tissue resistance × contact time. The median age of the patients was 64years (range 40-79years), and 17 patients were male. The median operative time was 287min (range 229-430min); median bleeding volume, 22ml (range 5-223ml); and the median number of harvested lymph nodes, 17 (range 4-40). The conversion rate to open surgery was 0%. A breakdown of Clavien-Dindo classification Grade ≥ II post-operative complications was as follows: surgical site infection, one patient (3.8%); ileus, one patient (3.8%); and urinary dysfunction, one patient (3.8%). No surgery-related or in-hospital deaths occurred. The pathological positive resection margin was not observed. Robotic TME for rectal cancer based on the theory of FUSE can be safely performed, making it a promising surgical procedure. It is suggested that robotic surgeons acquire surgical operation skills with monopolar devices based on the principles of FUSE, which may lead to an increased quality of robotic TME.

Knowledge representation and acquisition for ethical AI: challenges and opportunities

Machine learning (ML) techniques have become pervasive across a range of different applications, and are now widely used in areas as disparate as recidivism prediction, consumer credit-risk analysis, and insurance pricing. Likewise, in the physical world, ML models are critical components in autonomous agents such as robotic surgeons and self-driving cars. Among the many ethical dimensions that arise in the use of ML technology in such applications, analyzing morally permissible actions is both immediate and profound. For example, there is the potential for learned algorithms to become biased against certain groups. More generally, in so much that the decisions of ML models impact society, both virtually (e.g., denying a loan) and physically (e.g., driving into a pedestrian), notions of accountability, blame and responsibility need to be carefully considered. In this article, we advocate for a two-pronged approach ethical decision-making enabled using rich models of autonomous agency: on the one hand, we need to draw on philosophical notions of such as beliefs, causes, effects and intentions, and look to formalise them, as attempted by the knowledge representation community, but on the other, from a computational perspective, such theories need to also address the problems of tractable reasoning and (probabilistic) knowledge acquisition. As a concrete instance of this tradeoff, we report on a few preliminary results that apply (propositional) tractable probabilistic models to problems in fair ML and automated reasoning of moral principles. Such models are compilation targets for certain types of knowledge representation languages, and can effectively reason in service some computational tasks. They can also be learned from data. Concretely, current evidence suggests that they are attractive structures for jointly addressing three fundamental challenges: reasoning about possible worlds + tractable computation + knowledge acquisition. Thus, these seems like a good starting point for modelling reasoning robots as part of the larger ecosystem where accountability and responsibility is understood more broadly.

Robotik retropubik prostatektomiye aşina cerrahlar için robot yardımlı perineal prostatektomi için öğrenme eğrisi

Objective: To investigate the learning curve for robot assisted laparoscopic radical perineal prostatectomy (robotic RPP) for surgeons who already perform transperitoneal robot assisted laparoscopic radical prostatectomy. Material and Methods: A total of initial 120 robotic RPP cases were analyzed for perioperative data from single surgeon performing to determine the learning curve. Perioperative all data are collected including operation time, estimated blood loss, postoperative length of stay, complications and positive surgical margin results. The consecutive patients were classified into four groups: cases 1–30 (Group 1), cases 31–60 (Group 2), cases 61–90 (Group 3) and cases 91-120 (Group 4). Results: Median age of 61.4 (46-73) years and PSA level was 8.4 (2-32). Mean operative time was 143.2 minutes, and the length of surgery progressively decreased over time (from group 1 to group 4; P&lt;001). Mean console time was 90.6 minutes and significant differences was found group 3 vs. 4 (p=0.047). The mean length of stay was 1.6 days, and significantly decrease after 60 cases over time (P&lt;0.001). Mean removal of the urethral catheter significantly earlier in group 4 (P1vs4=0.012). There was no statistically significant difference between the groups with respect to pathologic tumor Gleason score, positive surgical margine of the specimen and complications. Conclusions: This study suggests that surgical qualification for robotic RPP can be obtained at least after 90 cases for an experienced robotic surgeon. Keywords: prostatectomy, robot-assisted, perineal, learning curve, prostate cancer

Robotic surgeons need more than just technical skills

Robotic surgeons need more than just technical skills

Obturator Nerve Injury in Robotic Pelvic Surgery: Scenarios and Management Strategies

BackgroundObturator nerve injury (ONI) is an uncommon complication of pelvic surgery, usually reported in 0.2–5.7% of cases undergoing surgical treatment of urological and gynecological malignancies involving pelvic lymph node dissection (PLND). ObjectiveTo describe how an ONI may occur during robotic pelvic surgery and the corresponding management strategies. Design, setting, and participantsWe retrospectively analyzed video content on intraoperative ONI provided by robotic surgeons from high-volume centers. Surgical procedureONI was identified during PLND and managed according to the type of nerve injury. Results and limitationsThe management approach varies with the type of injury. Crush injury frequently occurs at an advanced stage of PLND. For a crush injury to the obturator nerve caused by a clip, management only requires its safe removal. Three situations can occur if the nerve is transected: (1) transection with feasible approximation and tension-free nerve anastomosis; (2) transection with challenging approximation requiring certain strategies for proper nerve anastomosis; and (3) transection with a hidden proximal nerve ending that may initially appear intact, but is clearly injured when revealed by further dissection. Each case has different management strategies with a common aim of prompt repair of the anatomic disruption to restore proper nerve conduction. ConclusionsONI is a preventable complication that requires proper identification of the anatomy and high-risk areas when performing pelvic lymph node dissection. Prompt intraoperative recognition and repair using the management strategies described offer patients the best chance of recovery without sequelae. Patient summaryWe describe the different ways in which the obturator nerve in the pelvic area can be damaged during urological or gynecological surgeries. This is a preventable complication and we describe how it can be avoided and different management options, depending on the type of nerve injury.

Robotic Cystectomy with Intracorporeal Urinary Diversion is Associated with Decreased Narcotic Consumption

Introduction: Improvements in robotic technology and surgeon experience have made intracorporeal ileal conduit urinary diversion (ICUD) following robot-assisted radical cystectomy (RARC) a reality. Thus, it is essential to understand the benefits and drawbacks to this technically challenging approach. This study investigates surgical and pain-related perioperative outcomes in patients who underwent ICUD compared to extracorporeal urinary diversion (ECUD) at a tertiary care center. Methods: We reviewed a prospectively maintained database of 198 patients who underwent robot-assisted radical cystectomy between January 2015 and October 2020. Surgical, functional, and pain-related perioperative outcomes were compared between 177 patients who received either ICUD or ECUD. Results and Conclusion: Among 177 patients, 107 (60.4%) patients underwent ECUD and 70 (39.6%) underwent ICUD. Patients who received ICUD had significantly lower narcotic consumption (P=.031). There were no significant differences across cohorts in operative time (P=.10), estimated blood loss (P=.958), blood transfusion rate (P=.267), overall survival (P=.485), LOS (P=.652), or 30-day readmissions (P=.080). Our study suggests that RARC with intracorporeal ileal conduit reduces post-operative narcotic use as compared to extracorporeal diversion. Further validation across multiple institutions will be required to elucidate the full advantage and/or disadvantage to this approach.