Management of patients who opt for radical prostatectomy during the coronavirus disease 2019 (COVID-19) pandemic: an international accelerated consensus statement.

OBJECTIVE: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. The objective of this work is to develop guidance on criteria for prioritisation of surgery and reconfiguring management pathways for patients with non-metastatic prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve a low likelihood of coronavirus disease 2019 (COVID-19) hazard if radical prostatectomy (RP) was to be carried out during the outbreak and whilst the disease is endemic. METHODS: We conducted an accelerated consensus process and systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n = 34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. The Consensus opinion was defined as ≥80% agreement and this was used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and measures developed to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritisation criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as 'COVID-19 cold' sites. CONCLUSION: Reconfiguring management pathways for patients with prostate cancer is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing RP within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

Robotic paediatric urology.

UNLABELLED: What's known on the subject? and What does the study add? Robot assisted laparoscopic surgery (RALS) is slowly gaining acceptance in the field of paediatric urology. Accumulating data on safety and efficacy when performing paediatric robotic urologic procedures has led paediatric urologists to gradually embrace increasingly more complex reconstructive surgeries. Indeed, the unique and delicate movements generated by the robotic system make this technology ideal for children who often require reconstructive procedures. We critically review the current role of RALS in paediatric urology and to analyse the published data, with a special emphasis on the most common applications. We also propose a structured plan to expedite training and the surgical 'learning curve'. OBJECTIVES: To critically review the current role of robot-assisted laparoscopic surgery (RALS) in paediatric urology and to analyse the published data, with a special emphasis on the most common applications. One of the greatest benefits of RALS has been the ability to truly spread the application of minimally invasive surgery to paediatric surgical patients. The unique attributes of the robotic interface make this technology ideal for children with congenital anomalies, who often require reconstructive procedures. We also propose a structured plan to expedite training and the surgical 'learning curve'. PATIENTS AND METHODS: Currently, almost all urological surgical procedures in children have been performed with the assistance of the robotic interface. The most commonly performed procedures include pyeloplasty, nephrectomy/hemi-nephrectomy and surgery for vesico-ureteric reflux. Initial series of bladder augmentation and appendicovesicostomy are available. RESULTS: Initial results with RALS are encouraging and have shown safety similar to open procedures, and outcomes at least equivalent to standard laparoscopy. Accumulating data have consistently shown that postoperative analgesia requirements and overall hospital stay are decreased. However, operative durations are significantly longer than their open counterparts, but this is decreasing as experience accumulates. CONCLUSIONS: RALS is already part of paediatric urological surgery. Larger single-institution case series and comparative studies with the open approach and multi-institutional meta-analyses will help to identify the benefits of RALS in paediatric urology.

Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-urethral anastomosis.

OBJECTIVES: To describe a technical modification during robotic-assisted simple prostatectomy (RASP) aiming to decrease perioperative blood loss, shorten the length of hospital stay and eliminate the need of postoperative continuous bladder irrigation. To describe perioperative outcomes, pathological findings and functional outcomes of our single-surgeon series using this technique. METHODS: We analysed six consecutive patients who underwent RASP using our technical modification between February and September 2010. Transrectal ultrasonography (TRUS) guided prostate biopsy was performed in all cases and revealed benign prostatic hyperplasia in two cases and benign prostatic hyperplasia plus chronic prostatitis in four cases. The mean estimated prostate volume in the TRUS was 157 ± 74 (range 90-300) mL and the average preoperative International Prostate Symptom score was 19.8 ± 9.6 (10-32). Two patients were in urinary retention before surgery. Our technique of RASP includes the standard operative steps reported during open and laparoscopic simple prostatectomy; however, with the addition of some technical modifications during the reconstructive part of the procedure. Following the resection of the adenoma, instead of performing the classical 'trigonization' of the bladder neck and closure of the prostatic capsule, we propose three modified surgical steps: plication of the posterior prostatic capsule, a modified van Velthoven continuous vesico-urethral anastomosis and, finally, suture of the anterior prostatic capsule to the anterior bladder wall. RESULTS: The patients' average age was 69 ± 4.9 (63-74) years; the mean estimated blood loss was 208 ± 66 (100-300) mL and the mean operative time was 90 ± 17.6 (75-120) min. All patients were discharged on postoperative day 1 without the need of continuous bladder irrigation at any time after RASP. No blood transfusion or perioperative complications were reported. The mean weight of the surgical specimen was 145 ± 41.6 (84-186) g. Histopathological evaluation revealed benign prostatic hyperplasia plus chronic prostatitis in five patients and prostatic adenocarcinoma (Gleason score 3+3, pT1a) with negative surgical margins in one patient. The mean serum prostate-specific antigen level decreased from 7 ± 2.5 (4.2-11) ng/mL preoperatively to 1.05 ± 0.8 (0.2-2.5) after RASP. Significant improvement from baseline was reported in the average International Prostate Symptom score (average preoperative vs postoperative, 19.8 ± 9.6 vs 5.5 ± 2.5, P= 0.01) and in mean maximum urine flow (average preoperative vs postoperative 7.75 ± 3.3 vs 19 ± 4.5 mL/s, P= 0.019) at 2 months after RASP. All patients were continent (defined as the use of no pads) at 2 months after RASP. CONCLUSIONS: Our modified technique of RASP is a safe and feasible option for treatment of lower urinary tract symptoms caused by large prostatic adenomas. Potential advantages of our technique include reduced blood loss, lower blood transfusion rates and shorter length of hospital stay with no need of postoperative continuous bladder irrigation. Larger series with longer follow-up are necessary to determine long-term outcomes in comparison to open simple prostatectomy or to the standard technique of RASP.

Incidence of lymphoceles after robot-assisted pelvic lymph node dissection.

OBJECTIVE: • To determine the incidence and predictive factors of lymphocele formation in patients undergoing pelvic lymph node dissection (PLND) during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: • Between April and December 2008, 76 patients underwent PLND during RARP for ≥cT2c, prostate-specific antigen level ≥10, Gleason score ≥7 prostate cancer. • All patients were prospectively followed up with pelvic computed tomography 6-12 weeks after the procedure. • All patients received s.c. heparin preoperatively and postoperatively. PLND was limited to zones 1 and 2 as defined by Studer. • Plasma-kinetic bipolar forceps were used for haemostasis during PLND. RESULTS: • At a mean follow-up of 10.8 weeks, 51% (39/76) of patients had developed a lymphocele. Of these 39 lymphoceles 32 (82%) were unilateral and seven (18%) were bilateral. • The mean (range) lymphocele size was 4.3 × 3.2 (1.5-12.3) cm; 41% of lymphoceles were <4 cm, 53.9% were 4-10 cm, and 5.1% were >10 cm in diameter. Six of the 39 lymphoceles (15.4%) were clinically symptomatic. The symptoms were as follows: pelvic pressure in five patients, abdominal distension with ileus in three patients, leg pain/weakness in one patient and costovertebral tenderness in one patient. Two lymphoceles required intervention. • On the logistic regression model the presence of nodal metastases, tumour volume in the prostate specimen and extracapsular extension (ECE) were independent risk factors for the development of a lymphocele. • There was no correlation between estimated blood loss, body mass index, pathological Gleason score or number nodes dissected and the presence of lymphocele. CONCLUSIONS: • The incidence of lymphoceles was higher than anticipated given the believed protective effect of the transperitoneal approach against lymphocele formation. • The risk of lymphocele seemed to increase linearly with the presence of more extensive disease, particularly ECE and nodal involvement. • The benefit of PLND during RARP should be weighed against the elevated risk of lymphocele formation and its potential complications.

Complex robotic reconstructive surgical procedures in children with urologic abnormalities.

PURPOSE OF REVIEW: Robot-assisted laparoscopic surgery (RALS) is evolving rapidly in the pediatric surgical field. The unique attributes of the robotic interface makes this technology ideal for children with congenital anomalies who often require reconstructive procedures. Furthermore, the system can generate extremely delicate movements in a confined working space such as the one generally found in the pediatric population. Herein, we critically review the current experience with RALS placing a special emphasis in children undergoing complex reconstructive surgical procedures worldwide. RECENT FINDINGS: A total of 42 original manuscripts on a variety of robot-assisted urologic surgical procedures in children were identified from a MEDLINE database search. Complex reconstructive procedures that are being currently performed include reoperative pyeloplasty, pyeloplasty in infants, pyelolithotomy, ureteropyelostomy/ureterostomy, bladder augmentation with or without appendico-vesicostomy, bladder neck sling procedure, among others. SUMMARY: Initial results with robot assistance are encouraging and have demonstrated safety comparable to open procedures and outcomes at least equivalent to standard laparoscopy. Future development of smaller instruments, incorporating tactile feedback, will likely overcome current limitations and spread out the use of this technique in younger children and more advanced procedures.

Continence, potency and oncological outcomes after robotic-assisted radical prostatectomy: early trifecta results of a high-volume surgeon.

OBJECTIVE: • To evaluate early trifecta outcomes after robotic-assisted radical prostatectomy (RARP) performed by a high-volume surgeon. PATIENTS AND METHODS: • We evaluated prospectively 1100 consecutive patients who underwent RARP performed by one surgeon. In all, 541 men were considered potent before RARP; of these 404 underwent bilateral full nerve sparing and were included in this analysis. • Baseline and postoperative urinary and sexual functions were assessed using self-administered validated questionnaires. • Postoperative continence was defined as the use of no pads; potency was defined as the ability to achieve and maintain satisfactory erections for sexual intercourse >50% of times, with or without the use of oral phosphodiesterase type 5 inhibitors; Biochemical recurrence (BCR) was defined as two consecutive PSA levels of >0.2 ng/mL after RARP. • Results were compared between three age groups: Group 1, ≤ 55 years, Group 2, 56-65 years and Group 3, >65 years. RESULTS: • The trifecta rates at 6 weeks, 3, 6, 12, and 18 months after RARP were 42.8%, 65.3%, 80.3%, 86% and 91%, respectively. • There were no statistically significant differences in the continence and BCR-free rates between the three age groups at all postoperative intervals analysed. • Nevertheless, younger men had higher potency rates and shorter time to recovery of sexual function when compared with older men at 6 weeks, 3, 6 and 12 months after RARP (P < 0.01 at all time points). • Similarly, younger men had higher trifecta rates at 6 weeks, 3 and 6 months after RARP compared with older men (P < 0.01 at all time points). CONCLUSION: • RARP offers excellent short-term trifecta outcomes when performed by an experienced surgeon. • Younger men had higher overall trifecta rates when compared with older men at 6 weeks, 3 and 6 months after RARP.

Techniques of nerve-sparing and potency outcomes following robot-assisted laparoscopic prostatectomy.

PURPOSE: Nerve sparing radical prostatectomy is the gold standard for the treatment of prostate cancer. Over the past decade, more and more surgeons and patients are opting for a robot-assisted procedure. The purpose of this paper is to briefly review different techniques and outcomes of nerve sparing robot assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: We performed a MEDLINE search from 2001 to 2009 using the keywords "robotic prostatectomy", "cavernosal nerve", "pelvic neuroanatomy", "potency", "outcomes" and "comparison". Extended search was also performed using the references from these articles. RESULTS: Several techniques of nerve sparing are available in literature for RALP, which have been described in this manuscript. These include, "the veil of Aphrodite", "athermal retrograde neurovascular release", "clipless antegrade nerve sparing" and "clipless cautery free technique". The comparative and the non comparative series showing outcomes of RALP have been described in the manuscript. CONCLUSIONS: The basic principles for nerve sparing revolve around minimal traction, athermal dissection, and approaching the correct planes. It has not been documented if any one technique is better than the other. Regardless of technique, patient selection, wise clinical judgment and a careful dissection are the keys to achieve optimal oncological outcomes following RALP.

High intensity focused ultrasound renal tissue ablation: a laparoscopic porcine model.

PURPOSE: High intensity focused ultrasound for renal lesions is still experimental. In a porcine model we evaluated the safety and efficacy of a newly designed laparoscopic high intensity focused ultrasound probe and software that allows real-time ultrasound guidance during renal tissue ablation. MATERIALS AND METHODS: A Sonatherm 600 high intensity focused ultrasound system with a newly designed laparoscopic high intensity focused ultrasound probe was used through a standard Endopath 18 mm port. A total of 16 lesions were created in 15 kidneys in a total of 8 animals and randomized into 2 groups, including acute with sacrifice 4 days postoperatively and subacute with sacrifice 14 days postoperatively. Lesion size and location varied for each surgical procedure to simulate various treatment scenarios. RESULTS: Mean +/- SD planned ablation volume was 7.1 +/- 5.1 cc and mean treatment time was 7.2 +/- 06.88 minutes. For all lesions an injury volume was observed with a central zone of complete necrosis and no viable tissue. Mean total injury volume was 6.5 + 3.5 cc (range 1.1 to 13.7), comparable to preoperative mean planned ablation volume (p = 0.84). Mean necrosis volume was 4.89 +/- 2.9 cc (range 0.8 to 10.5), appreciably lower than preoperative mean planned ablation volume (p = 0.33). Presence of the collecting system interposed with the treatment region did not impact the injury volume-to-planned ablation volume ratio or the necrosis volume-to-planned ablation volume ratio. No animals died before study completion. Two intraoperative complications occurred, including a back wall musculature burn and a ureteral burn. CONCLUSIONS: Laparoscopic high intensity focused ultrasound for renal tissue using the newly developed probe was feasible and efficacious. The ability to perform renal high intensity focused ultrasound through an 18 mm laparoscopic port offers a new alternative for renal tumor ablation.

Serum creatinine can be used as a surrogate for glomerular filtration rate in single renal unit models.

BACKGROUND AND PURPOSE: Single renal unit models are invaluable for studies in renal physiology, transplantation and response to ischemic injury. Glomerular filtration rate (GFR) is commonly used for evaluation of renal function. Measuring the GFR involves relatively complicated and expensive systems. In this study we determined whether serum creatinine (Scr) can predict the GFR in this model. MATERIALS AND METHODS: Right laparoscopic nephrectomy was performed in 46 female pigs weighing 25 kg-30 kg. Twelve days later the left kidney was exposed to various periods of warm ischemia (30, 60, 90, and 120 minutes). Scr and GFR (using the iohexol clearance method) were determined preoperatively and at postoperative days 1, 3, 8, 15, 22 and 29. A total of 244 pairs of Scr and GFR values were analyzed to determine a formula for predicting GFR (pGFR) from Scr. RESULTS: Scr range was 1.2 mg/dl -29 mg/dl and GFR range was 1.8 ml/min -180.5 ml/min. The empiric formula deduced from the database for calculating pGFR from Scr was: pGFR = (217 divided by Scr) minus 0.2. pGFR correlated well with the actual GFR (R(2) = 0.85). The graphs for pGFR were almost indistinguishable from the graphs for actual GFR in every single animal. The results and conclusions of the experiments using either actual or predicted GFR were identical. CONCLUSIONS: We conclude that in a single renal unit porcine model using ischemia as the insult to the kidney, expensive actual measurements of GFR can be reliably replaced by Scr based calculated GFR.

Comparison of laparoscopic and open partial nephrectomy in clinical T1a renal tumors.

PURPOSE: Partial nephrectomy has been established as a standard of care for T(1a) renal tumors. Laparoscopic partial nephrectomy (LPN) has been described as more difficult to perform than open partial nephrectomy (OPN). We compare our series of LPN and OPN. PATIENTS AND METHODS: From October 2002 to January 2006, 76 LPNs were performed for patients with clinical T(1a) tumors. These patients were matched with a cohort of patients who underwent OPN for solitary tumors of 4 cm or smaller in diameter. The cohorts were compared with regard to demographics, perioperative data, and outcomes. RESULTS: The patient populations were demographically similar. Although mean tumor size was smaller in the laparoscopic cohort (2.5 v 2.9 cm, P=0.002), the OPN cohort demonstrated shorter operative (193 v 225 min, P=0.004) and ischemia times (20.5 v 32.8 min). LPN was associated with less blood loss (212 v 385 mL, P<0.001) and shorter hospital stay (2.5 v 5.6 days, P<0.001), however. One positive margin occurred in each of the LPN and OPN cohorts. Intraoperative complications were similar, although LPN was associated with fewer postoperative complications. Of note, two LPN (2.6%) patients had emergent reoperation and complete nephrectomy because of postoperative hemorrhage. CONCLUSIONS: Despite increased operative and ischemia times, LPN patients demonstrated quicker recovery and fewer postoperative complications. Two patients in the LPN group, however, had emergent complete nephrectomy because of hemorrhage. We conclude that LPN is still an evolving alternative to OPN in patients with small renal tumors.

Urinary and sexual function outcomes among different age groups after robot-assisted laparoscopic prostatectomy.

PURPOSE: We present an age-stratified prospective assessment of urinary and sexual function of 300 patients after robot-assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: Subjective assessment data of continence and potency were collected for different age groups (<50, 50-59, and > or =60 years old) preoperatively, and at 1, 3, 6, and 12 months after RALP. Health-related quality of life questionnaires evaluated return of baseline urinary and sexual function at the same time intervals. RESULTS: The three age groups included 21, 129, and 150 patients (aged <50, 50-59, and >60 years old, respectively). Using Kaplan-Meier curves, younger men achieved subjective continence significantly earlier than older age groups when age groups were compared using a 60-year-old cut-off point (P = 0.02). However, subjective continence was noted to be equal among all age groups after 1 year of follow-up. Time to recovery of subjective potency among age groups shows a significant difference in favor of the younger age group (P = 0.01) Objective urinary function is equal between age groups at all time points, while objective sexual function assessment showed a trend toward better results in the younger age group. CONCLUSIONS: Younger men will likely have an earlier return of continence and potency compared to older men after RALP. However, continence outcomes were noted to be equal among age groups after I year of follow-up, while younger men continue to report superior potency outcomes compared to older men over the first postoperative year. Such findings are valuable in counseling older men undergoing this procedure.

Efficacy of the argon beam coagulator alone in obtaining hemostasis after laparoscopic porcine heminephrectomy: a pilot study.

INTRODUCTION: The argon beam coagulator (ABC) is used in combination with other hemostatic agents and suture renorrhaphy to obtain hemostasis after laparoscopic partial nephrectomy. We performed a pilot study evaluating the efficacy of the ABC-alone in obtaining hemostasis during laparoscopic heminephrectomy (LHN) in a porcine model. METHODS: Eight pigs (4 small (30 kg-40 kg) and 4 large (70 kg-80 kg)), underwent bilateral LHN. Hemostasis then was obtained by using the ABC at 120W as a single modality. The collecting system was not repaired. The hilum was unclamped and the renal defect observed for 20 minutes with pneumoperitoneum pressure of 4 mmHg. The animals were survived for 24 hours at which time they were sacrificed and necropsy performed. RESULTS: All small pigs underwent LHN successfully. Mean pre- and post-op Hgb were 11.2 g/dl and 9.8 g/dl, respectively (p=0.12). In one of the animals, ABC at 150W was required to obtain hemostasis. All but one of the large pigs underwent LHN successfully. One of the animals had continuous bleeding despite ABC after right LHN and a completion nephrectomy was performed. Pre and postoperative Hgb for the large pigs were 9.9 g/dl and 9.3 g/dl, respectively (p=0.24). CONCLUSIONS: The ABC-alone was successful in obtaining hemostasis in all but two of the renal units in both small and large pigs. The two hemostatic failures were noticeable immediately after hilar unclamping. Our data suggest that ABC-alone provides adequate hemostasis when applied to small-caliber vessels. Further long term studies are needed to fully evaluate the efficacy of the ABC.

Internet survey of management trends of urethral strictures.

OBJECTIVES: The management of urethral stricture is often complex and the decision to proceed to urethroplasty may be difficult. A variety of factors are used by urologists to help guide this decision. We sought to conduct a survey to define current management trends and referral patterns in the treatment of urethral stricture disease. METHODS: An internet survey was conducted using the email directory for the AUA North Central Section. Survey design focused on urologist demographics and practice type, practice trends for treating urethral strictures, and referral patterns. Results were analyzed to assess for demographic parameters influencing management and referral trends. RESULTS: Responses were received from 84/600 (14%) urologists. Despite 95% of respondents reporting the recent treatment of urethral stricture, the majority of urologists reported performing no urethroplasties within the same time period. Complicated repairs (posterior, buccal) were performed by only a few of the respondents. A variety of factors were used by urologists to help decide at what point urethroplasty should be pursued. However, the importance of these factors varied significantly. CONCLUSIONS: Our data suggest that the treatment algorithm for urethral strictures is complex and varies considerably between urologists. The decision to perform urethroplasty may be particularly difficult. Finally, patient referral appears to play a significant role in stricture management. Treatment guidelines based on objective data are needed.

Embolization of renal-artery pseudoaneurysm after laparoscopic partial nephrectomy for angiomyolipoma: case report and literature review.

BACKGROUND: Renal-artery pseudoaneurysm (RAP) is a well-described complication of trauma or percutaneous urologic procedures. Delayed bleeding from an RAP is rare after partial nephrectomy. CASE REPORT: We present a 49-year-old woman who, 24 days after undergoing a laparoscopic right partial nephrectomy for a mesophytic 2.5-cm tumor, developed gross hematuria. Prompt CT imaging, followed by therapeutic angio-embolization of a third-order segmental renal artery with coils, treated the pseudoaneurysm successfully. CONCLUSIONS: Renal-artery pseudoaneurysm is a rare, potentially life-threatening, condition that often is difficult to diagnose and requires a high index of clinical suspicion. Early use of selective angio-embolization minimizes morbidity and maximizes renal conservation. The etiology, diagnosis, and management are discussed.

In-vitro gliding resistance of Lapra-Ty clip on polypropylene and glycolide sutures.

BACKGROUND AND PURPOSE: The LapraTy clip (LTc) is a useful tool for supplementing knot-tying during reconstructive laparoscopic surgery. However, data regarding its safety and efficacy are scarce. We critically assessed the in-vitro performance of the LTc over different sizes of two suture materials commonly used during reconstructive procedures. MATERIALS AND METHODS: The gliding resistance (GR) of one or two LTcs was tested on various sizes of both Polysorb and Prolene sutures. The GR of each suture was then compared with its breaking strength. Forces were measured using a Vernier Force Sensor. RESULTS: The GR of one LTc was significantly lower than the breaking strength of all Polysorb and Prolene suture sizes with the exception of 7-0 Prolene, with which the suture broke before the LTc slipped off. When two LTcs were placed sequentially, the GR increased significantly compared with a single LTc and was equal to or greater than the breaking strength for Polysorb 3-0 to 5-0 and Prolene 3-0 to 6-0. The percentage of GR over breaking strength was inversely related to suture size and was significantly greater with Prolene than with the Polysorb suture of the same size. CONCLUSIONS: Our results provide a better understanding of the resistive force an LTc offers before slipping and therefore failing. The results observed with Prolene sutures are encouraging and must be further investigated in an animal study to confirm the safety of the LTc when used during reconstructive procedures.

Impact of collecting-system repair during laparoscopic partial nephrectomy.

PURPOSE: Laparoscopic partial nephrectomy (LPN) is a complex procedure frequently reserved for small, peripherally located renal tumors. Deep, infiltrating lesions often necessitate collecting system repair (CSR), mandating further intracorporeal suturing and reconstruction. We compared our experience with LPN where CSR was and was not required after tumor resection. PATIENTS AND METHODS: Between October 2002 and December 2005, 84 patients underwent LPN. Tumor excision with pelvicaliceal system injury occurred in 52 patients, whereas 32 patients required no CSR. Perioperative and pathologic data were compared in the two groups. RESULTS: Tumors with CSR were larger (mean 2.9 cm v 2.1 cm for non-CSR procedures; P = 0.001) and had larger pathologic specimen weights (mean 58.2 g v 21.8 g; P = 0.05). Blood loss (mean 210 mL) and hospital stay (mean 2.7 days) were similar in the two groups. Warm ischemia time (WIT) (mean 36.6 v 27.7 minutes; P < 0.001) and operative time (mean 238 v 207 minutes; P = 0.03) were longer in the CSR group. The intraoperative hemorrhage rate (7.7% v 9.4%; P = 0.34) and rate of conversion to open surgery (7.7% v 9.4%; P = 0.29) were similar, as were the incidences of postoperative bleeding (7.7% v 3.1%; P = 0.28) and urinary leakage (1.9% v 0; P = 0.62). CONCLUSION: Laparoscopic partial nephrectomy involving CSR is a technically demanding procedure that necessitates longer WIT and overall surgical time. However, when performed by an experienced laparoscopic surgeon, comparable complication rates and blood loss are observed. Technical variations for hemostasis, such as argon-beam coagulation and FloSeal and the use of the LapraTy clip for pelvicaliceal and parenchymal suture repair may facilitate LPN for more deeply invasive tumors.

Robotic radical prostatectomy learning curve of a fellowship-trained laparoscopic surgeon.

BACKGROUND AND PURPOSE: Several experienced practitioners of open surgery with limited or no laparoscopic background have adopted robot-assisted laparoscopic radical prostatectomy (RLRP) as an alternative to open radical prostatectomy (RRP), demonstrating outcomes comparable to those in large RRP and laparoscopic prostatectomy series. Thus, the significance of prior laparoscopic skills seems unclear. The learning curve, with respect to operative time and complications, in the hands of a devoted laparoscopic surgeon has not been critically assessed. We evaluated the learning curve of a highly experienced laparoscopic surgeon in achieving expertise with RLRP. PATIENTS AND METHODS: We prospectively evaluated 150 consecutive patients undergoing RLRP by a single surgeon between March 2003 and September 2005. The first 25 cases were performed with the assistance of a surgeon experienced in open RRP. Data were compared for the first, second, and third groups of 50 cases. Demographic data were similar for the three groups. Urinary and sexual function data were evaluated subjectively and objectively using the RAND-36v2 Survey and the UCLA PCI preoperatively and at 3, 6, and 12 months postoperatively. RESULTS: The mean operative time, blood loss, and conversion rate decreased significantly with increasing experience. All open conversions occurred during the first 25 cases. Intraoperative and postoperative complication rates were similar among groups. Although the differences were not significant, urinary and sexual function recovery improved with experience. CONCLUSION: The RLRP learning curve for a fellowship-trained laparoscopic surgeon seems to be similar to that of laparoscopically naive yet experienced practitioners of open RRP. The RLRP is safe and reproducible and even during the learning curve can produce results similar to those reported in large RRP series. The importance of assistance by an experienced open RRP surgeon during the learning curve cannot be overemphasized.

Case report: radiofrequency ablation-induced renal-pelvic obstruction resulting in nephrectomy.

Radiofrequency ablation (RFA) has emerged as a minimally invasive nephron-sparing treatment for small (<4-cm) renal tumors. Post-RFA complications have been reported. We describe a patient who developed complete renal-pelvic obstruction after RFA. To our knowledge, this is the first such case to be reported and the second reported renal-unit loss as the result of collecting-system obstruction after RFA.

Da Vinci robot error and failure rates: single institution experience on a single three-arm robot unit of more than 700 consecutive robot-assisted laparoscopic radical prostatectomies.

BACKGROUND AND PURPOSE: Previous reports have suggested that a 2% to 5% device failure rate (FR) be quoted when counseling patients about robot-assisted laparoscopic radical prostatectomy (RLRP). We sought to evaluate our FR on the da Vinci system. PATIENTS AND METHODS: Since February 2003, more than 800 RLRPs have been performed at our institution using a single three-armed robotic unit. A prospective database was analyzed to determine the device FR and whether it resulted in case abortion or open conversion. Intuitive Surgical Systems provided data concerning the system's performance, including its fault rate. Error messages were classified as recoverable and non-recoverable faults. RESULTS: Between February 2003 and November 2006, 725 RLRP cases were available for evaluation. There were no intraoperative device failures that resulted in a case conversion. Technical errors resulting in surgeon handicap occurred in 3 cases (0.4%). Four patients (0.5%) had their procedures aborted secondary to system failure at initial set-up prior to patient entrance to the operating room. Data analysis retrieved from the da Vinci console reported on a total of 807 procedures since 2003. Only 4 cases (0.4%) were reported from the Intuitive Surgical database to result in either an aborted or a converted case, which compares favorably with our results. Since the last computer system upgrade (September 2005), the mean recoverable and non-recoverable fault rates per procedure were 0.21 and 0.05, respectively. CONCLUSIONS: For all the advanced features the da Vinci system offers, it is surprisingly reliable. Throughout our RLRP experience, device failure resulted in case conversion, procedure abortion, and surgeon handicap in 0, 0.5%, and 0.4% of procedures, respectively. As such, a lowered device FR of 0.5% should be used when counseling patients undergoing RLRP. To avoid futile general anesthesia, a policy should be enforced to ensure that the da Vinci system is completely set up before the patient enters the operating room.

Sural nerve grafting in robotic laparoscopic radical prostatectomy: interim report.

BACKGROUND AND PURPOSE: Sural nerve grafting for patients undergoing prostatectomy has been previously reported using open and minimally invasive methods. We report our experience with sural nerve grafting during robot-assisted laparoscopic radical prostatectomy (RLRP). MATERIALS AND METHODS: Patients with preoperative potency and a minimum of 6 months follow-up were included in this prospective review. A total of 333 patients were identified between February 2003 and January 2006 who met these criteria including 22 of the 25 patients who underwent sural nerve grafting. Patients were divided into 5 groups to compare unilateral and bilateral sural nerve cohorts with non-nerve-sparing and unilateral and bilateral nerve-sparing groups. Patients were followed prospectively using health-related quality-of-life questionnaires. RESULTS: Twenty-two patients underwent sural nerve grafting that included three bilateral grafts. Mean follow-up was 14 months. There was no statistical difference in patients' ages, body mass index, preoperative prostate-specific antigen level, blood loss, complications, and positive margin rate. Operative time was statistically longer for both sural graft cohorts when compared with unilateral (without graft) and bilateral nerve sparing cohorts. No significant differences in subjective or objective sexual function, sexual bother, or urinary function were seen with 6 and 12 months follow-up, possibly related to smaller sural cohorts. Graft-related complications include leg pain in one patient. CONCLUSION: Sural nerve grafting during RLRP is technically feasible and safe and offers improved dexterity and visualization deep within the pelvis. However, a larger randomized cohort of patients will be required to validate any improved benefits afforded by the robot system.