Robotic Surgical Approach Research Articles

Comparison of Surgical Outcomes of Robotic and Conventional Approaches in Patients with Pre- and Poststyloid Parapharyngeal Space Tumors

Benefits and drawbacks of robotic surgical approaches for parapharyngeal space (PPS) tumors remain undetermined. The purpose of this study is to compare surgical outcomes of PPS tumor patients who underwent robotic surgery with those of patients who received conventional surgical treatment. We retrospectively analyzed clinicopathologic data from 136 patients who underwent surgical removal of PPS tumors via conventional or robotic approaches. We identified PPS tumors in pre- and poststyloid regions in 87 (64%) and 49 (36%) patients, respectively. There were 48 (35.3%) pleomorphic adenomas, 36 (26.5%) schwannomas, and 24 (17.6%) paragangliomas. Conventional surgical techniques were performed in 83 patients, and robotic surgical approaches were administered to 53 patients. Transcervical-parotid and transcervical approaches were most commonly performed in conventional surgery, while transoral and retroauricular approaches were the preferred surgical methods in robotic surgery for pre- and poststyloid PPS tumors, respectively. Robotic surgery resulted in less estimated blood loss during poststyloid PPS tumor surgery. Postoperative cranial nerve complications were noted in 36 of 83 cases (43.4%) in the conventional surgery group and in 17 of 53 cases (32.1%) in the robotic surgery group. Intraoperative tumor spillage of pleomorphic adenoma showed no significant differences between the two groups (13.6% in conventional vs. 15.4% in robotic surgery). The mean follow-up time was 4.9 ± 3.4years, and recurrences were observed in two patients during follow-up without a significant difference between the two groups (4.5% in conventional vs. 3.8% in robotic surgery). Robotic surgery in PPS tumors is feasible through transoral, retroauricular, or combined approaches and provides treatment outcomes comparable to those of conventional open surgery.

Robotic distal subtotal gastrectomy with D2 lymphadenectomy for advanced gastric cancer: a case report and technical description

Robotic systems have revolutionized the way we perform minimally invasive surgery and has facilitated the evolution of traditional laparoscopic gastric surgery. Surgeons have several advantages that can overcome some of the well-known limits of laparoscopy: three-dimensional vision, articulated instruments, the absence of tremors. These can give greater dexterity and precision in dissection and suturing movements that are key elements when performing complex and gentle reconstruction to restore digestive continuity. The present case shows the technical details and tips and tricks of a robotic surgical approach for a subtotal gastrectomy.

Robotic-Assisted First Rib Resection: Our Experience and Review of the Literature

Thoracic outlet syndrome (TOS) comprises a constellation of signs and symptoms that arise from neurologic and vascular compression of the brachial plexus and subclavian vasculature, respectively. Surgical decompression of the neurovascular structures is often indicated to alleviate TOS. We report here our robotic surgical approach and experience for resection of the first rib. Between July 2014 and January 2017, 17 patients who underwent robotic-assisted first rib resection at our institution were reviewed. Nine women and 8 men with a mean age of 45 ± 11 years had a robotic-assisted first rib resection; 8 for neurogenic TOS and 9 for venous TOS. There were no complications or conversion to open surgery. The mean operative time was 113.2 ± 55.3 minutes. Length of stay was a mean of 1.8 ± 1.9 days. Length of rib resected was 5.8 ± 0.5 cm. Anticoagulation for the venous TOS cohort was Xarelto, for a mean of 5.1 ± 1.8 months. Short-term follow-up (mean 10.3 ± 4.9 days) revealed resolution of symptoms in all patients, with patent vasculature on venogram for the entire venous TOS cohort. Further follow-up at 2 months and 6 months revealed that all patients remained symptom free. Based on our institution's experience with the robotic-assisted approach to first rib resection, we feel that it is a feasible approach that could be added to the armamentarium of the thoracic surgeon.

Robotic versus open primary ventral hernia repair: A randomized controlled trial (Robovent Trial)

BackgroundThe objective of the present study is to compare the outcomes open PVHR and robotic PVHR. Methods/DesignThe present study will be a randomized single-blinded controlled trial with intention-to-treat analysis comparing robotic PVHR to open PVHR in adult patients undergoing elective PVHR with a defect ranging between 1–5 cm. Patient refusing to participate, not able to give informed consent, with history of intra-abdominal surgery contraindicating a robotic surgical approach will be excluded. The intervention will consist in laparoscopic robotically assisted trans-abdominal pre-peritoneal epigastric or umbilical PVHR with closure of fascial defect and non-adsorbable mesh reinforcement. The control will be open pre-peritoneal epigastric or umbilical hernia repair with closure of fascial defect and non-absorbable mesh reinforcement. The primary outcome will be the incidence of wound-related complication within 1 month. The secondary outcomes will be esthetic satisfaction, pain, pain-killers consumption, general complications, costs, operative time and early hernia recurrence. DiscussionOpen PVHR is potentially associated to more wound-related complications, but has the advantages of cost-effectiveness, short operative time and totally extra-peritoneal repair. Laparoscopic PVHR has lower wound-related complications but implies placing the mesh in intra-peritoneal position, requires advanced laparoscopic skills, usually does not allow the closure of the defect, and can lead to excessive pain and pain-killers consumption. Robotic PVHR uses the same laparoscopic access as laparoscopic PVHR, but thanks to the extended range of motion given by the robotic system, allows defect closure, pre-peritoneal placement of the mesh and requires less technical skills.In the present randomized controlled trial, we expect to show that robotic PVHR leads to better wound-related outcomes than open PVHR. Trial registrationThe present randomized controlled trial was registered into clinicaltrials.gov under registration number NCT04171921.

Intraoperative near infrared fluorescence for detecting sentinel lymph node in the robotic surgical approach of endometrial cancer

Intraoperative near infrared fluorescence for detecting sentinel lymph node in the robotic surgical approach of endometrial cancer

Intraoperative near infrared fluorescence for detecting sentinel lymph nodes in the robotic surgical approach of endometrial cancer

In recent years sentinel lymph node (SLN) mapping has emerged as an attractive investigational approach for the treatment of gynecological cancers, and in particular, endometrial cancer (EC). In fact, radical lymphadenectomy may have no therapeutic benefit in patients with early-stage EC who have low probability of lymph nodes involvement; subsequently, SLN mapping may decrease unnecessary lymph node dissections. In recent years, the number of minimally invasive procedures for gynecologic oncology has increased, with robotic procedures rising remarkably. Robotic SLN evaluation by intraoperative near infrared fluorescence (INIF) imaging system (Firefly™, Intuitive Surgical Inc., Sunnyvale, CA, USA) is an innovative surgical tool, which allows for a rapid conversion from the normal robotic view to that for detecting fluorescent indocyanine green (ICG). The aim of this video is to describe the use of this tool and technical outcomes of SLN dissection during our single-center experience in the robotic surgical approach of patients with early endometrial cancer.

Robotic surgery does not affect upstaging of T1 renal masses.

Partial nephrectomy is the mainstay of treatment for localized kidney cancer. A proportion of patients are upstaged post-operatively to locally advanced disease (pT3a). We aimed to identify the incidence of upstaging to pT3a during partial nephrectomy and its relationship to a robotic approach. The National Cancer Database was queried for patients diagnosed with cT1M0 disease between 2010 and 2015 who underwent an open or robotic partial nephrectomy with final stage pT1-3a. Our primary outcome was rate of upstaging to pT3a in patients undergoing partial nephrectomy and secondary outcomes were stage migration, rate of positive margins, and overall survival (OS). The relationship between open and robotic surgery was examined. Logistical regression and Kaplan-Meier analyses were performed. Of 68,976 patients identified, 5.9% of patients were upstaged from cT1 to pT3a post-operatively. The incidence of upstaging to pT3a disease has increased from 5.7% in 2010 to 6.9% in 2015. Similarly, the proportion of patients undergoing a robotic approach is also increasing (31.6-64.4%); however, a robotic approach is not associated with pT3a upstaging on multivariable analysis. The probability of being upstaged was significantly proportional to increasing tumor size (OR 2.634-11.641, p < 0.05). pT3a disease was associated with a significant increase in positive margins (10.7% vs 5.0%, p < 0.001). Interestingly, pT3a patients with positive margin had worsened survival (5-year OS 75.5% vs 65.9%, p < 0.001). A robotic surgical approach to partial nephrectomy does not increase risk of upstaging to pT3a disease. Those who are upstaged have increased risk of positive margins and associated risk of decreased survival.

A Brief Report on Survival After Robotic Lobectomy for Early-Stage Lung Cancer

IntroductionRobotic-assisted surgery has become the first choice for several conditions since its introduction in clinical practice in 2000. However, the U.S. Food and Drug Administration has recently raised a warning against the use of robotic surgical approaches for the cure and prevention of cancer following the publication of two studies focused on endometrial cancer. We conducted an internal audit to retrospectively analyze our experience to assess the safety and feasibility of robotic-assisted surgery compared to open surgery. MethodsWe selected a 5-year period to guarantee at least 2 years of follow-up (2011–2016) and identified 1139 patients who underwent lobectomy for NSCLC in our division. The primary data set analyzed included 544 early-stage clinical N0 patients (348 open and 196 robotic surgeries). We compared 131 patients of each group individually matched, with demographic and clinical characteristics almost identical. ResultsNo difference was observed between the cohorts, either in terms of recurrence-free survival (hazard ratio: 1.09; p = 0.55) or overall survival (hazard ratio: 0.86; p = 0.36). The 5-year recurrence of disease risk and overall survival were 24.9% and 83.2%, respectively, in the open group and 24.6% and 86.1%, respectively, in the robotic group. ConclusionsThese data underline that robotic-assisted lobectomy for early NSCLC is a safe and feasible technique with adequate long-term and progression-free survival compared to open surgery.

Transoral robotic surgery for hilo-parenchymal submandibular stones: step-by-step description and reasoned approach

The conservative transoral approach to hilo-parenchymal submandibular stones has been proposed as an alternative to traditional sialadenectomy. The main purpose is to preserve the gland and eliminate the risk of a cervical scar and damage to the marginal mandibular branch of the facial nerve. The spread of transoral robotic surgery has favoured its application not only in the oropharynx, but also in the anterior oral cavity. This article describes a transoral robotic approach for hilo-parenchymal submandibular stones. In January 2019, two patients with a right and a left hilo-parenchymal submandibular stone of 15mm and 8mm, respectively, underwent removal of the stone with transoral robotic surgery using the Si Da Vinci surgical robot. The procedure was performed successfully and tolerated well, with a one-night hospitalization. There were no complications such as lingual nerve damage, painful gland swelling, infection, or ranula. The patients were followed up clinically and ultrasonographically for the first 3 months to verify symptom relief and persistence of stones; no symptoms or stones were found. The transoral robotic surgical approach seems to be safe and adequate for the conservative management of large hilo-parenchymal submandibular stones. An adequate diagnosis together with proper docking and an appropriate approach to the oral floor is mandatory.

Variation in Positive Surgical Margin Status After Radical Prostatectomy for pT2 Prostate Cancer.

We evaluated patient, hospital, and cancer-specific factors associated with positive surgical margin (PSM) variability after radical prostatectomy in pT2 prostate cancer in the United States. A total of 45,426 men from 1152 hospitals with pT2 prostate cancer and known margin status after radical prostatectomy were identified using the National Cancer Database (2010-2015). Data on patient, cancer, hospital factors, and surgical approach were extracted. A mixed effects logistic regression model was computed to examine factors associated with PSM and partial R2 values to assess the relative contributions of patient, cancer, and hospital variables to PSM status. Median PSM rate of 8.5% (interquartile range, 5.2%-13.0%). Robotic (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.83-0.99) and laparoscopic (OR, 0.74; 95% CI, 0.64-0.90) surgical approach, academic institution (OR, 0.87; 95% CI, 0.76-1.00) and high hospital surgical volume (>297 cases [OR], 0.83; 95% CI, 0.70-0.99) were independently associated with a lower PSM. Black men (OR, 1.13; 95% CI, 1.01-1.26) and adverse cancer-specific features (prostate-specific antigen [PSA], 10-20; PSA >20; cT3 stage; Gleason 7, 8, 9-10; all P > .01) were independently associated with a higher PSM. Patient-specific, hospital-specific, and cancer-specific factors had a contribution of 2.3%, 3.9%, and 15.2%, respectively, to the variation in PSM. Facility had a contribution of 23.7% to the variation in PSM. Cancer-specific factors account for 15.2% of PSM variation with the remaining 84.8% of PSM variation due to patient, hospital, and other factors not accounted within the model. Noncancer-specific factors represent addressable factors that are important for policy-makers in efforts to improve patient outcome.

Roux-en-Y gastric bypass: systematic review and Bayesian network meta-analysis comparing open, laparoscopic, and robotic approach

The Roux-en-Y gastric bypass (RYGB) is performed via an open (OpenRYGB), laparoscopic (LapRYGB), or robotic (RoRYGB) approach. Previous review evidence is limited to pairwise meta-analysis, and RoRYGB versus OpenRYGB comparison is lacking. The aim of this network meta-analysis was to globally compare short-term outcomes within the open, laparoscopic, and robotic surgical approaches to RYGB. PubMed, EMBASE, and Web of Science databases were consulted. A fully Bayesian network meta-analysis was performed to compare OpenRYGB, LapRYGB, and RoRYGB. Nineteen studies, for a total of 276,732 patients, were included. Overall, 28.8% of the patients underwent OpenRYGB, 67.3% LapRYGB, and 3.9% RoRYGB. The 30-day mortality was significantly lower for both LapRYGB and RoRYGB versus OpenRYGB (risk ratio [RR] = .64, 95% credible interval [CrI] .46–.97, and RR = .49, 95% CrI .24–.99, respectively). The overall complication rate was significantly lower for both LapRYGB and RoRYGB versus OpenRYGB (RR = .63, 95% CrI .42–.91, and RR = .60, 95% CrI .33–.95, respectively). Anastomotic leak rate was similar for LapRYGB and RoRYGB versus OpenRYGB (RR = 1.10, 95% CrI .67–1.81, and RR = .95, 95% CrI .45–2.12, respectively). Surgical site infection (RR = .42, 95% CrI .30–.75, and RR = .24; 95% CrI .13–.58, respectively) and pulmonary complications (RR = .57, 95% CrI .45–.77, and RR = .42; 95% CrI .25–.76, respectively) were significantly lower for LapRYGB and RoRYGB versus OpenRYGB. No differences were found when postoperative bleeding, thromboembolic complication, 30-day reoperation, and 30-day hospital readmission were considered. This network meta-analysis suggests that both LapRYGB and RoRYGB appear to be safer compared to OpenRYGB with regard to 30-day mortality, overall complication rate, surgical site infection rate, and pulmonary complication rate. The surgical management of morbid obesity through RYGB is evolving, and the adoption of innovative minimally invasive techniques may improve patient outcomes.

Robotic surgery improves transfusion rate and perioperative outcomes using a broad implementation process and multiple surgeon learning curves.

Data from a randomized trial suggest transfusion rates are similar for robotic and open prostatectomy. The objective of this study was to compare perioperative outcomes of robotic and open prostatectomy at a Canadian academic centre. A retrospective review of all prostatectomies performed by all surgeons at The Ottawa Hospital between 2009 and 2016 was completed. Cases and outcomes were identified using an administrative data warehouse. Extracted data included patient factors (age, body mass index, American Society of Anesthesiologists score, Elixhauser comorbidity score), operative factors (length of operation, surgical approach, anesthesia type), and perioperative outcomes (length of recovery room and hospital stay, transfusion rate, hospital cost). Baseline characteristics and outcomes were compared between robotic and open surgical approaches. The primary outcome was transfusion during the index admission. A total of 1606 prostatectomies were performed by 12 surgeons during the study period (840 robotic, 766 open). The rate of transfusion was lower in patients undergoing robotic compared to open surgery (0.6% vs. 11.2%; p<0.001). The robotic prostatectomy cohort had a shorter length of stay in the recovery room (155.7 vs. 231.1 minutes; p<0.001) and shorter length of hospital admission (1.4 vs. 2.8 days; p<0.001). Hospital costs per case were approximately $800 more for robotic prostatectomy ($11 475 vs. $10 656; p<0.001). This hospital-wide analysis revealed that robotic prostatectomy is associated with a lower transfusion rate compared to the open approach. Further studies emphasizing patient-reported outcomes are needed.

Primary Trocar Insertion - Tips and Tricks for Easy Access

Objective: This video reviews three primary trocar entry techniques and discusses the relevant anatomy and potential challenges associated with obtaining primary access. We hope to improve the knowledge and comfort with primary trocar entry for gynecologic surgeons and to encourage a laparoscopic or robotic surgical approach even in more challenging cases.

Survey of pelvic reconstructive surgeons on performance of opportunistic salpingectomy at the time of pelvic organ prolapse repair.

Opportunistic salpingectomy (OS) at the time of benign hysterectomy has recently emerged as a potential primary preventive modality for ovarian cancer. Our objective was to determine whether the reported rate of OS at the time of prolapse surgery is similar to the rate of OS at the time of gynecologic surgery for non-prolapse indications. An anonymous online survey was sent to the Society of Gynecologic Surgery members. Responses were divided into surgeons who did and did not perform OS at the time of prolapse repair. Differences between surgeons who did and did not perform OS were evaluated using the chi-square test. Multivariable logistic regression was used to identify which responses related to increased odds of performing OS. There were 117(33.1%) completed responses; of these, 98 (83.8%) reported performing OS at the time of prolapse repair, which was similar to the reported rate of OS at the time of hysterectomy for non-prolapse indications, 82.1%. After multivariable logistic regression, performance of salpingectomy at the time of hysterectomy for a non-prolapse indication (aOR: 17.9, 95% CI: 3.11-42.01), use of a laparoscopic or robotic surgical approach (aOR 14.1, 95% CI: 1.81-32.21) and completion of an FPMRS fellowship (aOR: 3.47, 95% CI: 1.20-10.02) were associated with a higher likelihood of performing OS at the time of prolapse repair. OS at the time prolapse repair is performed more frequently with concomitant hysterectomy compared with OS at the time of post-hysterectomy prolapse repair and is similar to rates of OS performed at the time of hysterectomy for non-prolapse indications.

282 - Robotic Cystotomy for Pessary Extraction with Vesicovaginal Fistula Repair

This video case presentation discusses the step-by-step robotic surgical approach to the removal of a pessary, via cystotomy, followed by vesicovaginal fistula and cystotomy repair. The case involves a 77-year-old woman who had a Gellhorn pessary placed 12 years prior, without further evaluation or removal, presenting with vaginal leakage of urine. Imaging, followed by cystoscopy, confirmed the pessary within the urinary bladder. A robotic approach to the foreign body extraction was then performed. A cystotomy was made for pessary removal. The vesicovaginal fistula was evaluated and closed in two layers, followed by a bladder closure in two layers. A pelvic drain was then inserted. The patient denied leakage of urine at her postoperative appointment. This robotic surgical approach demonstrates ease of dissection, a method for thorough anatomy surveillance, and a method for successful repairs in complicated urogynecologic cases.

Robotic thyroidectomy and parathyroidectomy: An initial experience with retroauricular approach.

New approaches for robotic-assisted thyroidectomy were recently described. The purpose of this study was to present the report of our initial experience using a retroauricular approach for thyroid and parathyroid surgeries. This is a prospective study that was conducted under institutional review board approval and all surgeries were performed by a single surgeon at a North American academic institution. Some patients underwent an additional concomitant neck lift surgery in addition to the thyroid surgery. Some cases were performed without the use of the robot and they have been evaluated compared with the robotic cases. Clinical characteristics, total operative time, blood loss, surgical outcome, and length of hospital stay were evaluated. Forty cases representing thirty-eight female patients were included in this study, which includes 37 thyroid lobectomies and 3 parathyroid surgeries. Mean age was 44 ± 13 years, and mean body mass index (BMI) was 26.9 ± 5.31. Mean thyroid nodule size was 2.01 ± 0.94 cm. All cases were completed successfully via a single retroauricular incision. There was no conversion to an open approach. Six of 38 patients underwent additional neck lift surgery with a mean total operative time of 189 ± 45 minutes. The mean operative time for the remaining 34 patients who underwent retroauricular robotic-assisted hemithyroidectomy without neck lift surgery was 156 ± 39 minutes. Five patients underwent an endoscopic, retroauricular approach to the thyroid and parathyroid without using the robot. Two of 38 patients developed postoperative hematoma, in whom one of them needed a surgical evacuation. There were no cases of permanent vocal cord paralysis or permanent hypoparathyroidism. However, 2 patients developed transient hoarseness, which resolved 9 weeks and 10 weeks postoperatively, respectively. Mean blood loss was 19.0 ± 30.93 mL. Twenty-one patients were discharged on the same day of surgery, 17 patients were discharged after an overnight stay, and the remaining 2 patients were discharged after 2 days. Single-incision retroauricular robotic hemithyroidectomy and parathyroidectomy can be safe and feasible and concomitant neck lift surgery can be offered in a select group of patients. In addition, the nonrobotic retroauricular approach can be performed safely; however, future studies are warranted to further evaluate the benefits and limitations of this novel robotic retroauricular surgical approach.

An Update on the Management of Neurogenic Bladder

This article seeks to review literature regarding neurogenic voiding dysfunction, focusing on findings presented in the last 5 years. During this time, there has been an increase in the number of modalities available to treat patients with neurogenic bladder. A few of these options include novel oral pharmaceuticals, newly FDA-approved intravesical therapies, more widespread use of neuromodulation for patients with neurogenic bladder, utilization of devices such as urethral slings, and a focus on robotic assisted surgical approaches. In addition, a number of long-term outcomes have been published regarding “gold standard” techniques that have been heavily utilized in the past. Finally, new basic science research efforts have been focused in the fields of regenerative medicine and tissue engineering working to either augment or replace the bladder. A number of therapies have been added to the armamentarium of neurogenic bladder, some of which have significantly changed the way patients are managed.

Robotic Cystotomy for Pessary Extraction With Vesicovaginal Fistula Repair

Study ObjectiveTo demonstrate a robotic approach to foreign body extraction and vesicovaginal fistula repair. DesignVideo case presentation with narration discussing the step-by-step robotic surgical approach to the removal of a pessary, via cystotomy, followed by vesicovaginal fistula and cystotomy repair. SettingUniversity of Louisville Hospital. The local Institutional Review Board deemed the video exempt from formal approval (Canadian Task Force Classification III). PatientA 77-year-old woman presented with complaints of vaginal leakage of urine, dysuria, and pelvic pain. She had a Gellhorn pessary placed 12 years prior without further evaluation or removal. The patient had a leukocytosis with a pseudomonal urinary tract infection. Imaging confirmed a Gellhorn pessary free floating within the urinary bladder. InterventionsThe patient was taken to the operating room for an exam under anesthesia where a copious amount of urine was found coming from the vagina. A small vesicovaginal fistula was appreciated but could not be thoroughly explored. Cystoscopy revealed the foreign object in the urinary bladder. A robotic approach to the foreign body extraction was then performed with the davinci Xi robot (da Vinci Xi Intuitive Surgical, Sunnyvale, CA). The pessary was evident in the bladder on abdominal entry. Cystotomy was performed with the monopolar curved scissors. A vaginal EEA sizer was found to be advanced through the vesicovaginal fistula. The pessary was then grasped and removed from the bladder. Bilateral ureteral orifices were visualized. The fistula was then closed in 2 layers with 3-0 vicryl V-loc sutures (Covidien Medtronic, St. Paul, MN). The bladder was then closed in 2 layers with 3-0 vicryl V-loc sutures. A no. 15 Jackson-Pratt drain was then inserted through the right lower quadrant port and placed in the pelvis under direct visualization. The pessary was then removed via mini-laparotomy. A Foley catheter was left in place for prolonged drainage for a total of 6 weeks because of the multiple bladder repairs on the inflamed tissue. The patient denied any leakage of urine at her following postoperative appointment. ConclusionA robotic surgical approach, as an alternative to vaginal surgery, improves ease of dissection, provides a method for thorough anatomy surveillance, and can be used for successful repairs in complicated urogynecologic cases.

Colorectal surgery in elderly patients: our experience with DaVinci Xi® System.

Robotic technology for colorectal surgery was introduced by Weber in 2002 to improve the benefits of the minimally invasive surgery already offered by the laparoscopic approach. To evaluate the feasibility and the efficacy of the application of robotic surgery in elderly patients affected by colorectal diseases. We reported the outcomes obtained during our first 50 colorectal robotic surgical performances with DaVinci Xi® System, and we compared the results assessed for patients younger or older than 70years. We examined 28 patients younger and 22 older than 70years who underwent colorectal robotic surgery in our institution from September 2014 to June 2016. We performed 15 right colectomies, 20 left colectomies, 15 rectal resections. Mean ASA score was significantly higher in the Elderly Group. No statistically significant differences have been revealed in terms of post-operative morbidity, hospital stay, first diet intake, first flatus canalization and oncological outcome. According to the prolonged operative time, robotic technology was initially reserved to young patients with good performance status in order to avoid systemic failures in elderly patients suffering from pre-existent comorbidities. Otherwise, once robotic approach safety and benefits in terms of better systemic outcomes were demonstrated, it started to be performed in elderly patients with satisfactory outcomes. Our experience revealed that robotic surgical approach is safe, feasible and offers many systemic benefits in elderly patients also with high ASA score. Age alone has not to be considered as exclusion criteria for robotic approach.

Surgical control and margin status after robotic and open cystectomy in high-risk cases: Caution or equivalence?

The benefits of robotic-assisted radical cystectomy (RARC) are unclear, especially in patients with high-risk disease (pT3/T4). We evaluated pathological and postoperative outcomes of RARC versus open radical cystectomy (ORC) in these patients. We identified bladder cancer patients treated with RARC or ORC from January 2010-August 2014. Clinicodemographic factors were examined for potential confounding. Our primary outcome of interest was positive soft-tissue surgical margins (STSMs). Secondary outcomes included post-operative complications and length of stay (LOS). We used logistic regression to define the association between clinical factors with outcomes of interest, focusing on patients with locally advanced disease. We identified 472 patients treated with ORC (407, 86.2%) or RARC (65, 13.8%) of which 215 (45.6%) were high-risk cases based on advanced pathologic stage (pT3/4). RARC patients were more commonly men (96.9 vs. 73.2%, p<0.01), had better performance status (ECOG0, 78.5 vs. 59.7%, p=0.031), and received less neoadjuvant chemotherapy (21.5 vs. 39.3%, p=0.006). Total (52.3 vs. 59.7%, p=0.26) and high-grade complication rates (13.8 vs. 19.7%, p=0.27) were similar, but median LOS was shorter after RARC (6 vs. 7days, p<0.01). On multivariate analysis, prior pelvic radiation (OR: 4.78, 95% CI: 2.16-10.57), and advanced tumor stage (OR: 3.06, 95% CI: 1.56-6.03) were independently associated with positive STSMs in high-risk patients but robotic surgical approach was not (OR: 0.81, 95% CI: 0.29-2.30; p=0.69). RARC had similar short-term postoperative outcomes compared to ORC and did not compromise oncological control in patients with extravesical disease.