BACKGROUND: 

Robot-assisted radical prostatectomy (RARP) is a rising minimally invasive treatment of localized prostate cancer (PC). We present our multicenter experience of 1,499 consecutive cases with an analysis of complication rates, oncologic, and functional outcomes.

PATIENTS AND METHODS: 

From March 2005 through December 2012, details of 1,499 patients were retrospectively analyzed. Transperitoneal approach using a da-Vinci robotic system was used to perform RARP. Perioperative characteristics and postoperative oncologic and functional outcomes are reported.

RESULTS: 

The mean age was 61.3 years (37-77). Mean PSA level was 8.3 ng/ml. According to D'Amico classification, the percentage of patients with low-, intermediate-, and high-risk disease cases were 65.0, 30.1, and 4.8 %, respectively. Mean operative time was 181.9 min. Mean estimated blood loss was 225.4 cc (30-1,250). Positive surgical margin (PSM) was detected in 212 (14.1 %) patients. PSM rates in pT2, pT3, and pT4 stages were 6.1, 37.1, and 100 %, respectively. The overall complication rate due to modified Clavien classification was 6.1 %. Mean follow-up time was 26.7 months. Continence, potency, and biochemical recurrence rates were 88.7, 58.2, and 2.9 %, respectively.

CONCLUSIONS: 

Our analyses including high-volume centers, which is the first largest series in Turkey, show that RARP is a safe procedure, has low PSM rates, high continence, and potency rates for the treatment of localized PC at experienced centers.

The case of a simultaneous robotic radical nephroureterectomy, genital tract and paravaginal nerve-sparing robotic radical cystectomy, super-extended pelvic lymph node dissection and intracorporeal Studer pouch construction on a 57-year old female patient with muscle invasive bladder and distal ureteral tumors, along with a hydroureteronephrotic nonfunctioning right kidney is presented. The entire surgery was completed through a total of 8 ports in 9.5 hours. The patient was discharged home on postoperative day-6 and a JJ-stent attached to the urinary catheter was removed altogether on postoperative day-21. This complex surgery can be done safely robotically with excellent oncological outcomes and no surgical and wound complications in the short term. 

BACKGROUND: 

Robot-assisted radical cystectomy (RARC) with intracorporeal diversion has been shown to be feasible in a few centers of excellence worldwide, with promising functional and oncologic outcomes. However, it remains unknown whether the complexity of the procedure allows its duplication in other non-pioneer centers. We attempt to address this issue by presenting our cumulative experience with RARC and intracorporeal neobladder formation.

METHODS: 

We retrospectively identified 62 RARCs in 50 men and 12 women (mean age 63.6 years) in two tertiary centers. Intracorporeal Studer neobladders were created, duplicating the steps of standard open surgery. Perioperative and postoperative variables and complications were analyzed using standardized tools. Functional and oncological results were assessed.

RESULTS: 

The mean operative time was 476.9 min (range, 310 to 690) and blood loss was 385 ml (200 to 800). The mean hospital stay was 16.7 (12 to 62) days with no open conversion. Perioperative complications were grade II in 15, grade III in 11, and grade IV in 5 patients. The mean nodal yield was 22.9 (8 to 46). Positive margins were found in in 6.4%. The 90- and 180-day mortality rates were 0% and 3.3%. The average follow-up was 37.3 months (3 to 52). Continence was achieved in 88% of patients. The cancer-specific survival rate and overall survival rate were 84% and 71%, respectively.

CONCLUSIONS: 

A RARC with intracorporeal neobladder creation is safe and reproducible in 'non-pioneer' tertiary centers with robotic expertise with acceptable operative time and complications. Further standardization of RARC with intracorporeal diversion is a prerequisite for its widespread use.

BACKGROUND AND OBJECTIVES: 

To compare open versus totally intracorporeal robotic-assisted radical cystectomy, bilateral extended pelvic lymph node dissection, and Studer urinary diversion in bladder cancer patients.

METHODS: 

A retrospective comparison of open (n = 42) versus totally intracorporeal (n = 32) robotic-assisted radical cystectomy, bilateral extended pelvic lymph node dissection, and Studer urinary diversion was performed concerning patient demographic data, operative and postoperative parameters, pathologic parameters, complications, and functional outcomes.

RESULTS: 

Patient demographic data and the percentages of patients with pT2 disease or lower and pT3-pT4 disease were similar between groups (P > .05). Positive surgical margin rates were similar between the open (n = 1, 2.4%) and robotic (n = 2, 6.3%) groups (P > .05). Minor and major complication rates were similar between groups (P > .05). Mean estimated blood loss was significantly lower in the robotic group (412.5 ± 208.3 mL vs 1314.3 ± 987.1 mL, P < .001). Significantly higher percentages of patients were detected in the robotic group regarding bilateral neurovascular bundle-sparing surgery (93.7% vs 64.3%, P = .004) and bilateral extended pelvic lymph node dissection (100% vs 71.4%, P = .001). The mean lymph node yield was significantly higher in the robotic group (25.4 ± 9.7 vs 17.2 ± 13.5, P = .005). The number of postoperative readmissions for minor complications was significantly lower in the robotic group (0 vs 7, P = .017). Better trends were detected in the robotic group concerning daytime continence with no pad use (84.6% vs 75%, P > .05) and severe daytime incontinence (8.3% vs 16.6%, P > .05). No significant differences were detected regarding postoperative mean International Index of Erectile Function scores between groups (P > .05).

CONCLUSIONS: 

Robotic surgery has the advantages of decreased blood loss, better preservation of neurovascular bundles, an increased lymph node yield, a decreased rate of hospital readmissions for minor complications, and a better trend for improved daytime continence when compared with the open approach.

INTRODUCTION: 

Robot-assisted radical cystectomy (RARC) plus intracorporeal urinary diversion is feasible. Few centers worldwide demonstrated comparable functional and oncologic outcomes. We reported a large series of RARC and intracorporeal diversion to assess its feasibility and reproducibility.

MATERIAL AND METHODS: 

We identified 101 RARCs in 82 men and 19 women (mean age 68.3 years) from October 2009 to October 2014. The patients underwent RARC and pelvic lymphadenectomy followed by intracorporeal urinary diversion (ileal conduit/ neobladder). Out of the 101 patients, 28 (27.7%) received intracorporeal ileal conduits and 73 (72.3%) intracorporeal neobladders. Studer pouch was performed in all the patients who underwent intracorporeal neobladder formation. Perioperative, functional and oncologic results including CSS and OS are reported.

RESULTS: 

Mean operative time was 402.3 minutes (205-690) and blood loss was 345.3 ml (50-1000). The mean hospital stay was 17.1 days (5-62). All the surgeries were completed with no open conversion. Minor complications (Grade I and II) were reported in 27.7% of patients while major complications (grade III and above) were reported in 36.6% of patients. The mean nodal yield was 20.6 (0-46). Positive ureteric margins were found in 8.9% of patients. The average follow-up was 27.5 months (1-52). Daytime continence could be achieved in 89.2% of patients who underwent intracorporeal neobladder. The 3-year cancer specific survival (CSS) and overall survival (OS) was 80.2% and 69.8% respectively.

CONCLUSIONS: 

RARC with intracorporeal diversion is safe and reproducible in 'non-pioneer' tertiary centers with robotic expertise having acceptable operative time and complications as well as comparable functional and oncologic outcomes.

Around 20%-30% of patients diagnosed with prostate cancer (PCa) still have high-risk PCa disease (HRPC) that requires aggressive treatment. Treatment of HRPC is controversial, and multimodality therapy combining surgery, radiation therapy, and androgen deprivation therapy have been suggested. There has been a trend toward performing radical prostatectomy (RP) in HRPC and currently, robot-assisted laparoscopic RP (RARP) has become the most common approach. Number of publications related to robotic surgery in HRPC is limited in the literature. Tissue and Tumor characteristics might be different in HRPC patients compared to low-risk group and increased surgical experience for RARP is needed. Due to the current literature, RARP seems to have similar oncologic outcomes including surgical margin positivity, biochemical recurrence and recurrence-free survival rates, additional cancer therapy needs and lymph node (LN) yields with similar complication rates compared to open surgery in HRPC. In addition, decreased blood loss, lower rates of blood transfusion and shorter duration of hospital stay seem to be the advantages of robotic surgery in this particular patient group. RARP in HRPC patients seems to be safe and technically feasible with good intermediate-term oncologic results, acceptable morbidities, excellent short-term surgical and pathological outcomes and satisfactory functional results.

INTRODUCTION: 

We assessed the incidence of contralateral prostate cancer (cPCa), contralateral EPE (cEPE) and contralateral positive surgical margins (cPSM) in patients diagnosed preoperatively with unilateral prostate cancer and evaluated risk factors predictive of contralateral disease extension.

METHODS: 

The occurrence of cPCa, cEPE and cPSM and the side-specific nerve-sparing technique performed were collected postoperatively from 327 men diagnosed with unilateral prostate cancer at biopsy. Parameters, such as the localization, proportion, and percentage of cancer in positive cores, were prospectively collected.

RESULTS: 

Overall, 50.5% of patients had bilateral disease, and were at higher risk when associated with a positive biopsy core at the apex (p = 0.016). The overall incidence of ipsilateral EPE and cEPE were 21.4% and 3.4%, respectively (p < 0.001). Compared to cPCa, ipsilateral disease was at an almost 4-fold higher risk of extending out of the prostate (p < 0.001). None of the criteria tested were identified as useful predictors for cEPE. The low incidence of cEPE in our cohort could limit our ability to detect significance. The overall incidence of ipsilateral PSM and cPSM were 15.3% and 5.8%, respectively (p < 0.001). More aggressive nerve-sparing was not associated with a higher incidence of PSM. Prostate sides selected for more aggressive nerve-sparing were associated with younger patients (p < 0.001), a smaller prostate (p = 0.006), and a lower percentage of cancer in biopsy material (p = 0.008).

CONCLUSION: 

Although the risk of cPCa is high in patients diagnosed with unilateral prostate cancer at biopsy, the risk of cEPE and cPSM is low, yet not insignificant. Contralateral aggressive nerve-sparing should be used with caution and should not compromise oncological outcome.

Currently, most renal masses are detected incidentally while still small in size because of the widespread use of radiological imaging, and most pheochromocytomas are localized in the adrenal glands as unilateral lesions. A 5 × 4-cm right adrenal mass and a 19 × 13-mm exophytic left renal mass were synchronously detected by contrast enhancement on computed tomography and magnetic resonance imaging in a 47-year-old male with hypertension. The patient's preoperative serum and 24-h urine catecholamine levels were elevated. Initially, robotic transperitoneal right adrenalectomy was performed, and histopathology confirmed a 4 cm pheochromocytoma. After 3 months, transperitoneal zero ischemia robotic left partial nephrectomy was performed, and histopathology demonstrated clear cell renal cell carcinoma, Fuhrman grade II, 17 mm in size with clear surgical margins. This case indicates that sequential robotic surgery is feasible and safe as a minimally invasive approach to remove bilateral renal and adrenal masses. Zero ischemia robotic partial nephrectomy is also feasible and safe for selected small renal masses. 

The aim of this study was to evaluate outcomes of robotic partial nephrectomy (RAPN) procedures. At two centers, 42 patients underwent RAPN. Radius, Exo/Endophytic, Nearness, Anterior/Posterior, Location (R.E.N.A.L.) nephrometry and PADUA scores of patients were calculated by computed tomography (CT) or magnetic resonance imaging (MRI). Intra- and perioperative (0-30 days) complications were evaluated using modified Clavien classification. A four-arm da Vinci-S robotic surgical system was used and outcomes were evaluated retrospectively. Mean age of the patients was 52.3 ± 6.5 years. Mean tumor size was 3.1 ± 1.0 (1.4-6.6) cm. R.E.N.A.L. nephrometry and PADUA scores were 6.0 ± 1.5 and 7.5 ± 0.9, respectively. Mean surgical time was 127.7 ± 18.7 minutes and estimated blood loss was 100 ± 18.1 cc. Mean warm ischemia time was 16.0 ± 8.9 (0-30) minutes. Intraoperative complications did not develop in any patient. Median hospital stay was 3.0 (2-6) days. Except for 17 patients, hilar clamping was performed in 25 patients. Histopathology results included 34 renal cell carcinoma (22 clear cell, 7 chromophobe cell, 4 papillary cell, and 1 clear papillary cell). Oncocytoma (n = 4), adenoma (n = 1), fibroadipose tissue (n = 1), papillary epithelial hyperplasia (n = 1), and chronic pyelonephritis (n = 1) were present. Surgical margins were negative in all patients. During a median follow-up period of 15.5 ± 10.9 (3-46) months, neither local recurrence nor distant metastasis was detected. In conclusion, RAPN is a safe, minimally invasive surgical approach, with excellent surgical and oncological outcomes in T1 kidney tumors. Zero ischemia off-clamp RAPN is also safe in selected masses with the advantage of avoiding complete renal ischemia. 

Copyright © 2015. Published by Elsevier Taiwan.

INTRODUCTION: 

We investigated whether anterior periprostatic fat (APPF) tissue removed during robotic radical prostatectomy (RARP) contains any lymph nodes (LNs).

MATERIAL AND METHODS: 

APPF tissues removed during RARP in 129 patients were evaluated histopathologically. Correlation with postoperative pathologic stage was made. Patients with a history of previous prostate or bladder surgery and radiation therapy were excluded.

RESULTS: 

Mean patient age, serum prostate specific antigen (PSA), prostate weight and body mass index (BMI) were 62.2 ±5.5 (range 45-74), 9.3 ±6.3 ng/dl (range 0.26-30.3), 60.3 ±27.2 grams (range 11.0-180) and 26.6 ±1.9 kg/m(2) (range 20.0-30.3), respectively. Overall, LNs in APPF tissues were detected in 14 (10.9%) patients with a mean LN yield of 1.1 ±0.7 LNs (range, 1-3). Among those found, no metastatic LN was detected. Of the patients with pT2a (n = 22), pT2b (n = 15), pT2c (n = 62) and pT3a (n = 21) disease, LNs in APPF tissues were detected in 1 (4.6%), 1 (6.7%), 11 (17.7%) and 1 (4.8%) patient in each group, respectively. Among the patients, LNs in APPF tissues were detected in 0 (0%), 5 (35.7%), 8 (57.1%) and 1 (7.1%) patients of underweight, optimal weight, overweight and obese patients due to body mass index, respectively.

CONCLUSIONS: 

In our series, LNs were detected in around 10% of the patients. Therefore, this fat should, not be pushed back during RARP but should be removed and sent for pathologic evaluation. Although no metastatic LN was detected in our series, the presence of metastatic LNs might have an impact on the oncologic outcomes of the patients and warrants further research.

CONTEXT: 

Radical cystectomy (RC) is associated with frequent morbidity and prolonged length of stay (LOS) irrespective of surgical approach. Increasing evidence from colorectal surgery indicates that minimally invasive surgery and enhanced recovery programmes (ERPs) can reduce surgical morbidity and LOS. ERPs are now recognised as an important component of surgical management for RC. However, there is comparatively little evidence for ERPs after robot-assisted radical cystectomy (RARC). Due to the multimodal nature of ERPs, they are not easily validated through randomised controlled trials.

OBJECTIVE: 

To provide a European Association of Urology (EAU) Robotic Urology Section (ERUS) policy on ERPs to guide standardised perioperative management of RARC patients.

EVIDENCE ACQUISITION: 

The guidance was formulated in four phases: (1) systematic literature review of evidence for ERPs in robotic, laparoscopic, and open RC; (2) an online questionnaire survey formulated and sent to ERUS Scientific Working Group members; (3) achievement of consensus from an expert panel using the Delphi process; and (4) a standardised reporting template to audit compliance and outcome designed and approved by the committee.

EVIDENCE SYNTHESIS: 

Consensus was reached in multiple areas of an ERP for RARC. The key principles include patient education, optimisation of nutrition, RARC approach, standardised anaesthetic, analgesic, and antiemetic regimens, and early mobilisation.

CONCLUSIONS: 

This consensus represents the views of an expert panel established to advise ERUS on ERPs for RARC. The ERUS Scientific Working Group recognises the role of ERPs and endorses them as standardised perioperative care for patients undergoing RARC. ERPs in robotic surgery will continue to evolve with technological and pharmaceutical advances and increasing understanding of the role of surgery-specific ERPs.

PATIENT SUMMARY: 

There is currently a lack of high-level evidence exploring the benefits of enhanced recovery programmes (ERPs) in patients undergoing robot-assisted radical cystectomy (RARC). We reported a consensus view on a standardised ERP specific to patients undergoing RARC. It was formulated by experts from high-volume RARC hospitals in Europe, combining current evidence for ERPs with experts' knowledge of perioperative care for robotic surgery.

Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Despite the finally acquired level 1 evidence, the urologic debate on open versus robotic prostatectomy still persists. This trial from Brisbane will encourage future studies that will better inform this debate and define what robotic surgery offers.

Copyright © 2016 European Association of Urology. All rights reserved.

Recurrence following radical cystectomy often occurs early, with >80% of recurrences occurring within the first 2 yr. Debate remains as to whether robot-assisted radical cystectomy (RARC) negatively impacts early recurrence patterns because of inadequate resection or pneumoperitoneum. We report early recurrence patterns among 717 patients who underwent RARC with intracorporeal urinary diversion at nine different institutions with a minimum follow-up of 12 mo. Clinical, pathologic, radiologic, and survival data at the latest follow-up were collected. Recurrence-free survival (RFS) estimates were generated using the Kaplan-Meier method, and Cox regression models were built to assess variables associated with recurrence. RFS at 3, 12, and 24 mo was 95.9%, 80.2%, and 74.6% respectively. Distant recurrences most frequently occurred in the bones, lungs, and liver, and pelvic lymph nodes were the commonest site of local recurrence. We identified five patients (0.7%) with peritoneal carcinomatosis and two patients (0.3%) with metastasis at the port site (wound site). We conclude that unusual recurrence patterns were not identified in this multi-institutional series and that recurrence patterns appear similar to those in open radical cystectomy series.

PATIENT SUMMARY: 

In this multi-institutional study, bladder cancer recurrences following robotic surgery are described. Early recurrence rates and locations appear to be similar to those for open radical cystectomy series.

OBJECTIVE: 

In this study we aimed to compare renal functions in patients who underwent robotic partial nephrectomy (RPN) with on-clamp and zero- ischemia techniques.

MATERIAL AND METHODS: 

Between 2009 and 2015, 12 off-clamp and 22 on-clamp RPN procedures were performed on a total of 34 patients in two centers. The main outcome parameters examined were serum creatinine, and estimated glomerular filtration rate (eGFR) during preoperative, immediate postoperative periods, and at postoperative 3rd months.

RESULTS: 

There were no statistically significant differences between on-clamp and zero- ischemia groups regarding age, ASA score, BMI, PADUA and R.E.N.A.L. nephrometry scores, operation time and tumor size (p>0.05). Significant differences were found in the duration of hospital stay (3.8±0.9 days vs. 3.0±0.9 days) and amount of blood loss (85.9±49.6 mL vs. 183.3±176.2 mL) between the on-clamp and zero-ischemia groups (p<0.05). Statistically significant differences were found between preoperative and immediate post-operative periods, in terms of eGFR and serum creatinine levels in both groups. Moreover, statistically significant differences were found between preoperative and postoperative 3rd month periods, in the on-clamp group in terms of eGFR and serum creatinine levels. In the zero-ischemia group, the decrease in eGFR and serum creatinine levels at postoperative 3rd month relative to the preoperative period was not statistically significant.

CONCLUSION: 

Off-clamp RPN technique is superior, in short-term outcomes involving renal functions, compared to on clamp approach. However, long- term data regarding the renal functions should be evaluated to arrive at a definitive decision.

PURPOSE: 

We sought to investigate the prevalence and variables associated with early oncologic failure.

MATERIALS AND METHODS: 

We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot-assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot-assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan-Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival.

RESULTS: 

A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38-5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00-6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21-3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001).

CONCLUSIONS: 

The incidence of early oncologic failure following robot-assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot-assisted radical cystectomy.

Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

In this practical review, we discuss current surgical techniques reported in the literature to perform intracorporeal urinary diversion (ICUD) after robotic radical cystectomy (RARC), emphasizing criticisms of single approaches and making comparisons with extracorporeal urinary diversion (ECUD). Although almost 97% of all RARCs use an ECUD, ICUD is gaining in popularity, in view of its potential benefits (i.e., decreased bowel exposure, etc.), although there are a few studies comparing ICUD and ECUD. Analyzing single experiences and the data from recent metanalyses, we emphasize the current critiques to ICUD, stressing particular technical details which could reduce operative time, lowering the postoperative complications rate, and improving functional outcomes. Only analysis of long-term follow-up data from large-scale homogeneous series can ascertain whether robotic intracorporeal urinary diversion is superior to other approaches.

BACKGROUND/AIM: 

The aim of this study was to gauge whether removal of a specimen with traction during robot-assisted laparoscopic radical prostatectomy causes a positive surgical margin or not.

MATERIALS AND METHODS: 

One hundred and sixty-nine patients with localized prostate cancer who underwent robot-assisted laparoscopic radical prostatectomy from 2009 to 2011 were included in the study. After dividing the patients into two groups, we recorded their characteristics and pre-op/post-op evaluations.

RESULTS: 

There were 111 and 58 patients in groups 1 (with traction) and 2 (without traction), respectively. We evaluated the patients' ages, follow-up time, body mass index (BMI), prostate-specific antigen (PSA) values, pre-op and post-op Gleason score values, pathological stage, positive surgical margin rates, and biochemical PSA recurrence rates. There was no statistically significant difference between the groups for age, pre-op PSA values, BMI, pre-op and post-op Gleason scores, positive surgical margin rates and biochemical recurrence rates. There was a significant difference between prostate weight, tumor volume, and clinical stage.

CONCLUSION: 

Removing the specimen with traction during robot-assisted laparoscopic radical prostatectomy does not cause a positive surgical margin. The incision should be as small as possible for cosmetic appearance.

Background: Prostatic leiomyoma is a benign and rare condition of the prostate. Robotic surgery is increasingly being applied in the surgical management of prostate cancer. Case Presentation: Herein, a mass lesion that was located in the posterior part of the prostate between seminal vesicles that was identified during robotic surgery is presented. This lesion further challenged the console surgeon during performing a robotic radical prostatectomy procedure for a 200 g large prostate with prostate cancer. Conclusion: Prostatic leiomyomas that are benign mesenchymal smooth muscle tumors might present as a posteriorly located mass lesion between seminal vesicles that could challenge the surgeon during surgery, which should be kept in mind.

A 50 year-old patient was referred to our department with severe obstructive lower urinary tract symptoms, suprapubic pain and rectal fullness that started after a perianal fistula operation performed one year ago. Radiologic evaluation showed a large pararectal cystic lesion with septa formation on the right side compressing the bladder and prostate. Aspiration of the cystic fluid attempted initially but was not successful. A robotic transperitoneal approach was applied and the cyst was excised completely. On 1-year follow-up, patient did not have any symptoms and cyst was completely disappeared on radiology.