Underwent Robot Assisted Laparoscopic Radical Research Articles

Experiences of patients who underwent robot assisted laparoscopic radical prostatectomy

Experiences of patients who underwent robot assisted laparoscopic radical prostatectomy

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

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

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

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

Robot Assisted Laparoscopic Repair of Sciatic Hernia (RASH): A Case Report

Sciatic hernia is a surgical rarity. One such hernia was incidentally diagnosed in a 79-year-old woman who underwent Robot assisted laparoscopic radical cystectomy for locally invasive bladder cancer. Intra-operatively, a patent hernia sac was noted in the sciatic notch. The hernia was successfully repaired during the same operation by using robot assisted laparoscopic technique. This appears to be the first robot assisted sciatic hernia repair in the world literature although it was done incidentally during another procedure. The technical descriptions of the operation are also applicable when isolated sciatic hernia repair is intended. A robot assisted laparoscopic repair is safe, feasible and well suited to the repair of sciatic hernias in women. The surgeon needs to be aware of this uncommon surgical pathology that may occur in women presenting with persistent chronic pelvic discomfort.

Evaluating Urinary Continence and Preoperative Predictors of Urinary Continence After Robot Assisted Laparoscopic Radical Prostatectomy

We evaluated urinary continence using a validated questionnaire in a series of consecutive patients who underwent robot assisted laparoscopic radical prostatectomy, and identified the preoperative predictors of the return to urinary continence. The clinical records of 308 consecutive patients who underwent robot assisted laparoscopic radical prostatectomy for clinically localized prostate cancer at a tertiary academic center were prospectively collected. All patients were continent before surgery. Urinary continence was evaluated using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form instrument. All of the patients reporting no leak in response to the question, "How often do you leak urine?" were defined as continent. A total of 273 patients (90%) were continent 12 months after robot assisted laparoscopic radical prostatectomy. Continent patients were significantly younger (61.4 +/- 6.4 vs 64.1 +/- 6.1 years, p = 0.02) than those who were incontinent. On univariable regression analysis patient age at surgery (OR 1.075, p = 0.024) and Charlson comorbidity index (OR 1.671, p = 0.007) were significantly associated with 12-month continence status. On multivariable analysis age (OR 1.076, p = 0.027) and Charlson comorbidity index (OR 1.635, p = 0.009) were independent predictors of continence rates. Using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form 90% of patients undergoing robot assisted laparoscopic radical prostatectomy reported no urine leak 12 months after surgery. Patient age at surgery and Charlson comorbidity index were independent predictors of the return to urinary continence, whereas notably no variable related to prostate cancer was significantly correlated with urinary continence.

Predictors of Positive Surgical Margins After Laparoscopic Robot Assisted Radical Prostatectomy

We identified the predictors of positive surgical margins in a series of patients undergoing robot assisted laparoscopic radical prostatectomy. We prospectively collected data from 322 patients who underwent robot assisted laparoscopic radical prostatectomy for clinically localized prostate cancer between April 2005 and October 2008, and who had not received any prior hormonal therapy. Positive surgical margins were observed in 95 cases (29.5%). Specifically positive surgical margins were at the apex in 22 cases (6.8%), anterior in 5 (1.6%) and posterolateral in 68 (21%). Among the preoperative variables prostate volume on transrectal ultrasound (HR 0.420, p = 0.002) and cT stage (HR 2.217, p = 0.008) were independent predictors of the presence of any positive surgical margin in the cohort while cT stage (HR 2.070, p = 0.025) and biopsy Gleason score (p = 0.019) were predictors of posterolateral positive surgical margins. Considering pathological variables only extraprostatic extension of the primary tumor was an independent predictor of any positive surgical margin (HR 11.852, p <0.001) and posterolateral positive surgical margins (HR 7.484, p <0.001) in the series. Of those patients with organ confined disease positive surgical margins were present in 21 (10.6%). Only perineural invasion was an independent predictor of any positive surgical margin (HR 4.096, p = 0.028) while a not statistically significant trend was identified with regard to posterolateral positive surgical margins (HR 6.938, p = 0.067). Pathological extension of the primary tumor was the most relevant predictor of positive surgical margins. In patients with organ confined disease the presence of perineural invasion was significantly associated with positive surgical margins.

Single Institution 2-Year Patient Reported Validated Sexual Function Outcomes After Nerve Sparing Robot Assisted Radical Prostatectomy

To identify surgeon specific factors for preserving sexual function (and minimize patient related factors) we report 2-year potency outcomes in men 65 years or younger with normal preoperative sexual function undergoing nerve sparing robot assisted laparoscopic radical prostatectomy. Between July 2004 and February 2006, 200 consecutive patients underwent robot assisted laparoscopic radical prostatectomy by 1 surgeon. Inclusion criteria were age 65 years or younger with normal baseline 5-item International Index of Erectile Function score of 22 to 25 and complete 2-year followup. Postoperatively potency was defined by a yes to "erections adequate for vaginal penetration" and "satisfactory erections" on prospective self-administered validated questionnaires with or without phosphodiesterase type 5 medications. Men also reported 5-item International Index of Erectile Function scores and erectile fullness of 0% to 10%, 25%, 50%, 75% or 100% compared to before surgery. A total of 62 patients met the inclusion criteria, and of these 3 were lost to followup and 1 was excluded from study due to receiving hormonal therapy. At 3 months 32.1% reported potency. At 24 months potency was 89.7% (52 of 58) overall, 93.0% (40 of 43) for bilateral and 80.0% (12 of 15) for unilateral nerve sparing. For potent men the mean 5-item International Index of Erectile Function score was 20.4 at 3 months vs 21.3 at 24 months. Mean erectile firmness at 24 months was 91% compared to preoperative baseline, with 34 of 52 (65%) reporting 100% of preoperative fullness. The 5-item International Index of Erectile Function score and fullness at 24 months were equivalent for unilateral nerve sparing and bilateral nerve sparing. Overall 90% of men reported return of potency at 24 months, and 46% returned to baseline with normal 5-item International Index of Erectile Function scores and 100% firmness. Remarkably there was no difference in 5-item International Index of Erectile Function scores or fullness between unilateral nerve sparing and bilateral nerve sparing.

The Impact of Prostate Gland Weight in Robot Assisted Laparoscopic Radical Prostatectomy

We determined whether prostate weight has an impact on the pathological and operative outcomes of robot assisted laparoscopic radical prostatectomy. We reviewed the records of 1,847 consecutive patients who underwent robot assisted laparoscopic radical prostatectomy at our institution. Variables were compared across quartile distributions of prostate size as defined by weight, including group 1-less than 30 gm, group 2-30 to 49.9, group 3-50 to 69.9 and group 4-70 or greater. Factors assessed in this analysis were patient age, body mass index, prostate specific antigen, Gleason score, pathological stage, margin status, operative time, blood loss, transfusion rate, length of stay and rehospitalization rate. Patients with a larger prostate (group 4) were older (mean age 66.2 years), had higher pretreatment prostate specific antigen (median 6.5 ng/ml), lower Gleason score (mean 6.3), longer operative time (mean 3.2 hours), higher estimated blood loss (median 250 cc) and longer hospital stay (p = 0.0002). There was a trend toward higher risk disease based on D'Amico risk stratification and positive margin status in group 1, although evidence of extracapsular extension was more common in groups 2 and 3. There was no association between prostate size and body mass index, lymph node status, blood transfusion rate, seminal vesicle involvement and rehospitalization rate. Robot assisted laparoscopic radical prostatectomy in patients with an enlarged prostate is feasible with slightly longer operative time, urinary leakage rates and hospital stay. Pathologically larger prostates are generally associated with lower Gleason score and risk group stratification. One-year continence rates and biochemical recurrence rates are similar across all groups.

Combined inguinal hernia repair with prosthetic mesh during transperitoneal robot assisted laparoscopic radical prostatectomy: A 4-year experience: Finley DS, Rodriguez E Jr, Ahlering TE, Department of Urology, University of California-Irvine, Orange, CA

Inguinal hernias are detected in 20% to 30% of patients undergoing radical prostatectomy. We report our experience with concomitant transperitoneal robot assisted laparoscopic radical prostatectomy and intraperitoneal inguinal herniorrhaphy using prosthetic mesh. A retrospective review was performed of the medical records of 533 consecutive robot assisted laparoscopic radical prostatectomies performed by 1 surgeon from June 2002 to April 2007. All cases that included combined herniorrhaphy were recorded in a prospective database, reviewed, and compared against a cohort of patients matched for body mass index and age who underwent robot assisted laparoscopic radical prostatectomy alone. A total of 49 concurrent herniorrhaphy procedures were performed in 40 patients for 31 unilateral (left side in 30 and right side in 19) and 9 bilateral inguinal hernias. Five patients underwent prior ipsilateral inguinal herniorrhaphy, and 3 each underwent contralateral and prior bilateral repair. Preoperatively, 15 of 40 patients (37.5%) had a definite inguinal hernia, 5 (12.5%) had noticeable weakness of the external ring, and 20 (50%) had a completely normal physical examination. Compared with a matched cohort undergoing robot assisted laparoscopic radical prostatectomy alone, there were no significant differences in smoking history, narcotic use, hospital stay, or complications. Hernia repair added approximately 10 minutes of operative time. Postoperatively, 1 of 49 hernias (2.0%) recurred at 4 months during a median follow-up of 15.3 months. There were no complications related to hernia repair. Concurrent repair of inguinal hernias during transperitoneal robot assisted laparoscopic radical prostatectomy using prosthetic mesh is technically feasible and effective, and without increased complications or morbidity.

Combined Inguinal Hernia Repair With Prosthetic Mesh During Transperitoneal Robot Assisted Laparoscopic Radical Prostatectomy: A 4-Year Experience

Inguinal hernias are detected in 20% to 30% of patients undergoing radical prostatectomy. We report our experience with concomitant transperitoneal robot assisted laparoscopic radical prostatectomy and intraperitoneal inguinal herniorrhaphy using prosthetic mesh. A retrospective review was performed of the medical records of 533 consecutive robot assisted laparoscopic radical prostatectomies performed by 1 surgeon from June 2002 to April 2007. All cases that included combined herniorrhaphy were recorded in a prospective database, reviewed and compared against a cohort of patients matched for body mass index and age who underwent robot assisted laparoscopic radical prostatectomy alone. A total of 49 concurrent herniorrhaphy procedures were performed in 40 patients for 31 unilateral (left side in 30 and right side in 19) and 9 bilateral inguinal hernias. Five patients underwent prior ipsilateral inguinal herniorrhaphy, and 3 each underwent contralateral and prior bilateral repair. Preoperatively 15 of 40 patients (37.5%) had a definite inguinal hernia, 5 (12.5%) had noticeable weakness of the external ring and 20 (50%) had a completely normal physical examination. Compared with a matched cohort undergoing robot assisted laparoscopic radical prostatectomy alone there were no significant differences in smoking history, narcotic use, hospital stay or complications. Hernia repair added approximately 10 minutes of operative time. Postoperatively 1 of 49 hernias (2.0%) recurred at 4 months during a median followup of 15.3 months. There were no complications related to hernia repair. Concurrent repair of inguinal hernias during transperitoneal robot assisted laparoscopic radical prostatectomy using prosthetic mesh is technically feasible and effective, and without increased complications or morbidity.