Total Console Time Research Articles

Combined robotic and open approach to excision of accessory bladder and urethral triplication

Management of urethral and bladder duplication anomalies centers on prevention of recurrent infections and preservation of renal function. We present a surgical approach to urethral triplication and bladder duplication utilizing a combined robotic and open approach. A 17-year-old male presenting with fevers and abdominal pain was found to have two accessory urethras dorsal to a normal orthotopic ventral meatus. A large cavity anterior to the bladder was identified on a computed tomography scan and drained of purulent fluid. After improvement with antibiotics, endoscopic evaluation revealed no distinct connection between the cavities. The patient subsequently underwent open excision of the urethral triplication followed by robotic excision of the accessory bladder. Total console time for the robotic portion was 2 hours 18 minutes and estimated blood loss was 30mL. The dissection was difficult due to reaction from prior infections, but the accessory bladder was able to be dissected off without opening the native bladder. The accessory bladder specimen was consistent with a urothelial lining exhibiting reactive changes. To our knowledge, robotic excision of a urethral/bladder duplication anomaly has not yet been described in the literature. The robotic approach allowed for excellent visualization and is technically feasible.

Robotic intracorporeal urinary diversion: technical details to improve time efficiency.

To present time-efficiency data during our initial experience with intracorporeal urinary diversion and technical tips that may shorten operative time early in the learning curve. Data were analyzed in the initial 37 consecutive patients undergoing robotic radical cystectomy and intracorporeal urinary diversion in whom detailed stepwise operative time data were available. Median age was 65 years and median body mass index was 27. Neoadjuvant chemotherapy was administered in 6 patients and 11 patients had clinical evidence of T3 or lymph node-positive disease. Each component of the operation was subdivided into specific steps and operative time for each step was prospectively recorded. Peri-operative and follow-up data up to 90 days and final pathological data were recorded. All procedures were completed intracorporeally and robotically without need for conversion to open surgery or extracorporeal diversion. Median total operative time was 387 vs 386 minutes (p=0.2) and median total console time was 361 vs 295 minutes (p<0.007) for orthotopic neobladder and ileal conduit, respectively. Median time for radical cystectomy was 77 minutes, extended pelvic lymph node dissection was 63 minutes, and diversion was 111 minutes (ileal conduit 92 minutes and orthotopic neobladder 124 minutes). Median estimated blood loss was 250 mL, and median hospital stay was 9 days. High grade (Clavien grade 3-5) complications at 30 and 90 days follow-up were recorded in 6 (16%) and 9 (24%) patients, respectively. Over a median follow-up of 16 months, 12 (32%) patients experienced disease recurrence and 9 (24%) died from bladder cancer. These correspond to 1-year recurrence-free and overall survival of 64% and 70%, respectively. Intracorporeal urinary diversion following robotic radical cystectomy can be safely performed and reproducible in a time-efficient manner even during the early learning curve.

Robotic single-site pelvic lymphadenectomy

Objective: To examine the feasibility of performing pelvic lymphadenectomy with robotic single site approach. Recent papers described the feasibility of robotic-single site hysterectomy [1–3] for benign and malign pathologies but only with the development of new single site 5mm instruments as the bipolar forceps, robotic single site platform can be safely utilized also for lymphadenectomy. Methods: A 65year-old, multiparous patient with a body mass index of 22.5 and diagnosed with well differentiated adenocarcinoma of the endometrium underwent a robotic single-site peritoneal washing, total hysterectomy, bilateral adnexectomy and pelvic lymphadenectomy. The procedure was performed using the da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA) through a single 2,5cm umbilical incision, with a multi-channel system and two single site robotic 5mm instruments. A 3-dimensional, HD 8.5mm endoscope and a 5mm accessory instrument were also utilized. Results: Type I lymphonodes dissection for external iliac and obturator regions was performed [4]. Total operative time was 210min; incision, trocar placement and docking time occurring in 12min. Total console time was 183min, estimated blood loss was 50ml, no intra-operative or post-operative complications occurred. Hospital discharge occurred on post operative day 2 and total number of lymphnodes removed was 33. Difficulties in term of instrument's clashing and awkward motions have been encountered. Conclusion: Robotic single-site pelvic lymphadenectomy using bipolar forceps and monopolar hook is feasible. New developments are needed to improve surgical ergonomics and additional studies should be performed to explore possible benefits of this procedure.

Simultaneous Bilateral Robotic Partial Nephrectomy: The Description of Our Technique

Introduction: The robot-assisted partial nephrectomy (RAPN) is becoming an increasingly common procedure due to the published encouraging outcomes. Very few articles have been reported concerning simultaneous bilateral RAPN1,2. In this video, we report our first case of simultaneous bilateral RAPN to show the feasibility of our technique and critically discuss both the advantages and disadvantages of this procedure. Run time: 7.36 minutes. Materials and Methods: A 69-year-old male patient visited our department due to incidental finding of bilateral mesorenal small renal masses (2.5 cm on the right and 3.5 cm on the left) suspicious for malignancy. The procedure was performed using a three-arms Da Vinci robot. We started from the right side with the patient in flank position. Port placement: a 12-mm periumbilical camera port, two 8-mm robotic ports in a wide V configuration centered on the renal tumor, an additional 12-mm assistant port on the midline between the umbilicus and symphysis pubis. A right RAPN without hilar clamping was performed. Renorraphy was performed with running outside-in monocryl 4/0 and 2/0 sutures preloaded with Hem-o-lok clips. After completing the right RAPN, the trocars were removed and the robot was undocked. Without interrupting the anesthesiological procedures, the patient was placed in a supine position and, after a 180° rotation of the surgical bed, was newly placed in a contralateral flank position. Using both the previous periumbilical and midline ports, two other 8-mm robotic trocars were placed centered on the left renal tumor. The robot was then redocked and a left RAPN without hilar clamping was also performed. Results and Conclusions: Total operation time: 285 minutes (total console time: 240 minutes). Estimated blood losses: 150 mL. Postoperative period: uneventful. Pathological examination: bilateral renal cell carcinoma (pT1aG1), negative surgical margins. Our technique is noteworthy for some aspects. We minimize the number of the ports (six overall). The disposition of the operatory room allows the rotation of the patient's bed and the quick redock of the robot. The operative time was acceptable for a bilateral procedure. The unclamping technique decreased the risk of postoperative renal insufficiency, which is more frequent after a bilateral procedure. The cost for two nephrectomies was decreased because we did not shut the robot down and used the same instruments. In conclusion, our experience was encouraging and confirmed the feasibility and safety of this procedure. The planning of our technique was time and cost effective with a cosmetic benefit for the patient. However, we think that an appropriate selection of the patients (mainly, regarding the size, the location of the tumors, or the preexisting condition of chronic renal insufficiency) and a very good skill in renal robotic surgery are really advisable before approaching this type of surgery. This is an original work that has never been published before and has not been submitted simultaneously to any other journal. All the authors have made a significant contribution to the findings and methods in the article. All the authors have read and approved the final draft. All the authors have no financial or commercial interests and did not receive any funding for their research. The corresponding author takes on the above responsibilities on behalf of the other authors. Runtime of video: 7 mins 36 secs

Experience With Robot-Assisted Laparoscopic Radical Prostatectomy at a Secondary Training Hospital: Operation Time, Treatment Outcomes, and Complications With the Accumulation of Experience

PurposeTo investigate the learning curve and outcomes of robot-assisted laparoscopic radical prostatectomy (RALP) performed by a relatively lower volume surgeon at a secondary training hospital.Materials and MethodsThe medical records and the surgery video recordings of 100 patients who underwent RALP by a single surgeon between March 2010 and January 2013 were reviewed. The first 10 cases were grouped into period 1, cases 11 to 40 into period 2, cases 41 to 70 into period 3, and cases 71 to 100 into period 4. The interval between the operations, the operative time for each step of the surgery, the total console time, and the operative outcomes were investigated.ResultsThe mean interval between surgeries was 10.6±9.3 days. The console time decreased progressively after the first 10 cases and reached under 3 hours after 75 cases. The time taken to begin dissection of the dorsal vein complex, for the division of the bladder neck, for lateral dissection with neurovascular bundle preservation, and for apex dissection decreased significantly with experience, although the time for vesicourethral anastomosis did not. The margin-positive rate of stage T2 patients was 27.4% (20/73), and the transfusion rate was 50% in period 1 patients and 3.3% in period 4 patients. No major complications occurred.ConclusionsIt is difficult to shorten the learning curve of surgeons in secondary training hospitals owing to the smaller number of cases and the irregular surgical intervals. Although the operation time was relatively longer, the surgical outcome and complication rates were comparable with those of surgeons at larger hospitals.

Modifications to Facilitate Extraperitoneal Robot-Assisted Radical Prostatectomy Post Kidney Transplant

Renal transplantation is the treatment of choice for patients with end-stage renal failure. With advances in immunosuppression, the short-term and long-term outcome has improved significantly. Subsequently, urologists are encountering more transplant recipients with genitourinary malignancies, and therefore urologists are becoming increasingly compelled to offer curative treatment options. We present modifications to facilitate E-RARP in these patients that include modified trocar arrangement, delayed bladder neck transection, utilizing the robotic Hem-o-lok applier, and posterior reconstruction of the anastomosis using a barbed V-loc suture. A 68-year-old male with a history of polycystic kidney disease, end-stage renal failure, and an allograft renal transplantation in the right iliac fossa, presented with T1c, Gleason 3+4 prostate cancer. He had a preoperative PSA of 6.93ng/mL, ASA score of 3, and a BMI of 26kg/m2. Follow-up for metastasis (MRI and bone scan) was negative. E-RARP was performed via the extraperitoneal approach using a 5-port 2-arm approach at an insufflation pressure of 10 mm Hg. The radical prostatectomy was successfully performed. Ureterovesical anastomosis was completed, and total console time was 130 minutes, with an estimated blood loss of 125mL. Final pathology was T2bNx, Gleason 3+4 with negative surgical margins. The patient was discharged with no change in serum creatinine or GFR. The catheter was removed on POD 10 with no intraoperative or immediate postoperative complications. E-RARP in the carefully selected renal allograft recipient is feasible and accomplished safely with technical modifications to avoid injuring the renal allograft, transplanted ureter, and ureteroneocystostomy.

Magnetic resonance or computerized tomography imaging to predict difficulty of robotic surgery for endometrial cancer.

To determine if the difficulty of a robotic hysterectomy for endometrial cancer can be predicted by MRI, CT or other methods. All robotic cases from 1 August 2006 through 30 July 2009 were identified. Data collected prospectively included co-morbidities, body mass index, surgical times, estimated blood loss (EBL), uterine weight, and pre- and postoperative complications. Those patients who received an MRI or CT scan prior to robotic hysterectomy had additional data gathered from imaging, including uterine volume, pelvic measurements and abdominal wall thickness. Cases were labeled difficult for the following reasons: outliers greater than 2 SD from the mean EBL, hysterectomy time and total console time. Additional factors identifying difficult cases included the need to undock to remove the specimen or conversion to laparotomy. Data were analyzed for their possible role in causing difficulty in a robotic hysterectomy. Comparative statistics utilized included chi-square and t-test, ANOVA and logistic regression analysis.From 2 August 2006 through 30 July 2009, 119 patients underwent robotic surgery for endometrial cancer and are included in this study. Of these patients, 25/119 (20.0%) were identified as difficult cases. Difficulty was found in those patients with greater than 2 SD from the mean for hysterectomy time, >90.9min (n=3, 2.5%), total console time of >178.1min (n=6, 5.0%), EBL >232cc (n=7, 5.9%) and undocking to remove the uterine specimen in 8 (6.7%) cases; 1/119 (0.8%) was converted to laparotomy. Lymphadenectomy (P=0.005) was associated with case difficulty. In a logistic regression analysis CT/MRI measurements of uterine volume greater than 793 cm³ and CT/MRI pelvimetry, as well as abdominal wall thickness were independent predictors of a difficult case (P=0.0116). MRI and CT scans can detect the probability that a robotic surgery will be difficult by determining uterine volume and pelvimetry; however, these were not the strongest predictors in our study. A narrow pelvic outlet as measured on CT/MRI and uterine volume of greater than 793cc should raise a flag of caution when planning robotic hysterectomy for endometrial cancer.

Posterior Reconstruction Before Anastomosis Improves the Anastomosis Time During Robot-Assisted Radical Prostatectomy

Our goal was to evaluate posterior reconstruction of the rhabdosphincter during robot-assisted radical prostatectomy and determine whether this technique decreased anastomotic time of a surgeon in training to perform vesicourethral reconstruction. We reviewed the first 25 robot-assisted prostatectomies performed by 2 urology surgeons in training (surgeon 1 and surgeon 2). The patient populations were matched for age, Gleason score, clinical stage, and PSA. Whereas surgeon 1 performed the vesicourethral anastomosis without posterior reconstruction, surgeon 2 reapproximated Denonvilliers' fascia of the posterior bladder to the rhabdosphincter. Time for each surgeon to complete the anastomosis and clinical factors was compared. Surgeon 1 had a median anastomosis time of 25 minutes (range, 17 to 48), whereas surgeon 2 had a median anastomosis time of 15 minutes (range, 10 to 30) (P<0.001). Biopsy Gleason score, pathological tumor stage, perineural invasion, median age at the time of surgery, PSA, prostate weight, and estimated blood loss were not significantly different between surgeons (P>0.05). Pathological Gleason score (P=0.045) and total console time (surgeon 1-216 minutes, surgeon 2-176 minutes; P=0.002) were significantly different between surgeons. Posterior reconstruction prior to anastomosis decreases anastomosis time for robotic surgeons in training.