Infiltration of liposome bupivacaine into the transversus abdominis plane for postsurgical analgesia in robotic laparoscopic prostatectomy: a pilot study.

BACKGROUND: Transversus abdominis plane (TAP) infiltration has been increasingly used for postsurgical analgesia in abdominal/pelvic procedures; however, duration/extent of analgesia with standard local anesthetics is limited. This pilot study assessed the preliminary efficacy and safety of two volumes of liposome bupivacaine administered via TAP infiltration in patients undergoing robotic laparoscopic prostatectomy. METHODS: In this single-center, open-label, prospective study, patients older than 18 years received TAP infiltration with liposome bupivacaine immediately after surgery. The first 12 patients received a total volume of 20 mL liposome bupivacaine (266 mg); the next 12 received 40 mL liposome bupivacaine (266 mg). The liposome bupivacaine was diluted with 0.9% normal saline. The primary efficacy measure was duration of analgesia, measured by time to first opioid administration. Secondary outcome measures included patient-assessed pain scores, opioid use, and opioid-related adverse events (AEs). RESULTS: Twenty-four patients received liposome bupivacaine (20 mL, n=12; 40 mL, n=12) and were included in the primary analysis. Three refused participation in a 10-day follow-up visit and did not complete the study. Median time to first opioid administration after surgery was 23 and 26 minutes for the 20 and 40 mL groups, respectively. Mean total amount of postsurgical opioids ranged from 25.4 to 27.3 mg; after hospital discharge to day 10, both groups required a mean of 0.7 oxycodone/acetaminophen tablets/day. Mean pain scores of 4.4 and 5.3 were reported at 1 hour and 3.1 and 3.9 at 2 hours postsurgery, with 20 and 40 mL doses, respectively. Neither group had mean scores higher than 3.0 at any further assessments. No opioid-related or treatment-related serious AEs were reported. CONCLUSION: Median time to first opioid administration did not differ between the two groups. No differences in secondary outcomes were observed on the basis of volume administered. These initial findings suggest further study of liposome bupivacaine administered via TAP infiltration as part of a multimodal analgesic regimen in laparoscopic robotic prostatectomy may be warranted.

Robot-assisted radical cystectomy in octogenarians.

BACKGROUND AND PURPOSE: Radical cystectomy is the standard of care for muscle-invasive bladder cancer; however, few patients over age 75 undergo cystectomy. Morbidity and mortality rates in this age group approach 60% and 10%, respectively. We sought to determine if minimally invasive surgery, in the form of robot-assisted radical cystectomy (RARC), may reduce morbidity and mortality associated with this operation in elderly patients. PATIENTS AND METHODS: After Institutional Review Board approval, all RARC performed between 2009 and 2012 from one institution were reviewed, and 23 cases in patients over the age of 80 were identified. Data analyzed included age, indication for cystectomy, American Society of Anesthesiologists score (ASA), Charlson Comorbidity Index, pathologic stage, estimated blood loss, transfusion rate, and 90-day morbidity and mortality rate. RESULTS: Twenty-three patients over the age of 80 years underwent RARC by a single surgeon (IT) between April 2009 and October 2012. Average age was 83.7 years (range 80-88 years) with average Charlson Comorbidity Index score of 4.3 (age-weighted 8.3). Indication for cystectomy was oncologic in all cases (21 bladder malignancy, 2 hemorrhagic cystitis in the setting of prostate cancer). The average blood loss and operative times were 208 mL (range 50-650 mL) and 253 minutes (range 175-365 min). Seven (30.4%) patients needed blood transfusions. The average length of hospital stay was 8.2 days (range 6-24 days). The overall complication rate within 90 days was 34.8% (8 patients) with no mortality. Longest follow-up is 34 months. CONCLUSIONS: RARC should be strongly considered for patients over the age of 80 with clinical indications for cystectomy. The complication rate is acceptable even in complicated patients with multiple comorbidities and those with previous abdominal surgery or pelvic radiation. Hospital stay remains shorter than with open surgery, and complication rates appear to be lower than previously reported for this age group.

Significance of prostate weight on peri and postoperative outcomes of robot assisted laparoscopic extraperitoneal radical prostatectomy.

INTRODUCTION: To determine the significance of prostate weight (PW) on clinical and pathological outcomes in patients undergoing da Vinci robot assisted laparoscopic extraperitoneal radical prostatectomy (EP-RARP). METHODS: From November 2008 to January 2010, 295 men underwent EP-RARP at our institution. We retrospectively reviewed our database and stratified patients into four groups based on pathologic PW: Group 1, less than 30 g; Group 2, 30 g to less than 50 g; Group 3, 50 g to less than 80 g; and Group 4, 80 g or larger. We prospectively compared these groups with respect to patient age, body mass index, prostate-specific antigen, Gleason score, pathological stage, margin status, operative time, blood loss, transfusion rate and length of stay. Statistical analysis was performed using SYSTAT 13 software. An analysis of variance (ANOVA) model was used to compare the continuous variables among the groups. Chi-square and Fisher's exact tests were used to compare categorical variables. RESULTS: Of the 295 patients, 10, 182, 91, and 12 had a PW of less than 30 g; 30 g to less than 50 g; 50 g to less than 80 g; and 80 g or larger, respectively. A significant difference was found in age, prostate weight and prostate-specific antigen values among the four groups (p < 0.05). Patients in Group 4 had larger prostates, were older (mean age 65 years), had higher pretreatment prostate-specific antigen (median 5.85 ng/mL) and lower Gleason score (mean 6.2). Based on the D'Amico risk stratification, our study showed a trend toward higher risk disease, presence of extra capsular extension, seminal vesicle invasion and positive margin status in Groups 1, 2 and 3 rather than in Group 4. No significant differences in operative time, estimated blood loss, transfusion rate, hospital stay, and postoperative complication rate were observed among the four groups. CONCLUSIONS: Da Vinci robot assisted laparoscopic extraperitoneal radical prostatectomy (EP-RARP) is feasible in patients with larger prostates, offering acceptable operative times, blood loss, hospital stay and complication rates. In our cohort of patients, we found pathologically smaller prostates are generally associated with higher Gleason score, higher risk group stratification and positive surgical margin status. Although technically challenging, increased prostate weight should not be considered a contraindication for EP-RARP if performed by experienced surgeons.

Pure laparoscopic donor nephrectomy: 3-year experience and analysis of a refined technique to maximize graft function.

PURPOSE: Strategies for vascular control and limiting warm ischemia time (WIT) vary between institutions for laparoscopic live donor nephrectomy (LLDN). We refined our technique and retrospectively determined whether it safely provides an allograft of comparable quality to published series. PATIENTS AND METHODS: Fifty consecutive LLDN between February 2003 and November 2006 were reviewed. Key technical aspects include placing the perfused kidney and transected ureter entirely within an endocatch bag, with the string externalized through an extended lateral port site incision. Vessels are then controlled with clips, or a Satinsky clamp for right sided veins. The extraction incision is completed and the bag immediately withdrawn and placed on ice. WIT ends with perfusion with cold UW solution. RESULTS: The series includes 42 left and 8 right kidneys. 13/50 (26%) demonstrated anatomical complexity (more than one artery, vein and/or ureter). Average operative time was 178 minutes. Average WIT was 128 seconds. Conversion to open surgery occurred in two patients, one to define challenging anatomy, and another for hemorrhage from the renal artery stump. Average blood loss was 76 ml. Average length of stay was 3.6 days. Average recipient creatinine was 1.26 mg/dl at discharge. Delayed graft function occurred in three recipients. ATN/slow normalization of creatinine occurred in four. Graft survival at one year was 96%. CONCLUSIONS: The refined technique of LLDN mimics important principles of open donor nephrectomy. Controllable variables which may impact graft function are optimized. WIT is amongst the lowest reported for pure laparoscopy, without increasing complication rates, blood loss, or operative time.

Complications of laparoscopic retroperitoneal lymph node dissection in testicular cancer.

OBJECTIVES: A proposed benefit of laparoscopic retroperitoneal lymph node dissection (LRPLND) is more favorable morbidity in comparison to open retroperitoneal lymph node dissection (RPLND). The objective of this review is to examine and summarize the literature regarding complications in both primary and post-chemotherapy LRPLND (PC-LRPLND) and, where appropriate, we include the opinions of the senior author regarding management. METHODS: A MEDLINE search was performed using the terms "laparoscopy" or "laparoscopic," "retroperitoneal lymph node dissection" or "RPLND," and "testicular neoplasms." Articles were included on the basis of study design and content. For series updated over time, an effort was made to include only the most recent data to avoid duplicate reporting of patients. RESULTS: In primary LRPLND, vascular injury is the most common complication, occurring in 2.2-20% of reported cases. Bowel injury is rarely reported but potentially catastrophic. Rates of retrograde ejaculation are less than 5%. Chylous ascites and lymphocele are delayed post-operative complications. Rarely reported complications include nerve injury, retroperitoneal hematoma, and ureteral injury requiring internal stent placement. PC-LRPLND is challenging, with high rates of conversion and complications. Hemorrhage is common. Retrograde ejaculation is several-fold more common in PC-LRPLND than in primary LRPLND. No peri-operative mortality has been reported for either LRPLND or PC-LRPLND. CONCLUSIONS: LRPLND and PC-LRPLND are technically demanding. Hemorrhage and vascular injury are the most commonly reported complications. Prospective studies will help clarify the proposed benefits of LRPLND.

Laparoscopic radical prostatectomy: omitting a pelvic drain.

PURPOSE: Our goal was to assess outcomes of a selective drain placement strategy during laparoscopic radical prostatectomy (LRP) with a running urethrovesical anastomosis (RUVA) using cystographic imaging in all patients. MATERIALS AND METHODS: A retrospective chart review was performed for all patients undergoing LRP between January 2003 and December 2004. The anastomosis was performed using a modified van Velthoven technique. A drain was placed at the discretion of the senior surgeon when a urinary leak was demonstrated with bladder irrigation, clinical suspicion for a urinary leak was high, or a complex bladder neck reconstruction was performed. Routine postoperative cystograms were obtained. RESULTS: 208 patients underwent LRP with a RUVA. Data including cystogram was available for 206 patients. The overall rate of cystographic urine leak was 5.8%. A drain was placed in 51 patients. Of these, 8 (15.6%) had a postoperative leak on cystogram. Of the 157 undrained patients, urine leak was radiographically visible in 4 (2.5%). The higher leak rate in the drained vs. undrained cohort was statistically significant (p = 0.002). Twenty-four patients underwent pelvic lymph node dissection (8 drained, 16 undrained). Three undrained patients developed lymphoceles, which presented clinically on average 3 weeks postoperatively. There were no urinomas or hematomas in either group. CONCLUSIONS: Routine placement of a pelvic drain after LRP with a RUVA is not necessary, unless the anastomotic integrity is suboptimal intraoperatively. Experienced clinical judgment is essential and accurate in identifying patients at risk for postoperative leakage. When suspicion is low, omitting a drain does not increase morbidity.

Laparoscopic radical prostatectomy: omitting a pelvic drain

PURPOSE: Our goal was to assess outcomes of a selective drain placement strategy during laparoscopic radical prostatectomy (LRP) with a running urethrovesical anastomosis (RUVA) using cystographic imaging in all patients. Materials and Methods: A retrospective chart review was performed for all patients undergoing LRP between January 2003 and December 2004. The anastomosis was performed using a modified van Velthoven technique. A drain was placed at the discretion of the senior surgeon when a urinary leak was demonstrated with bladder irrigation, clinical suspicion for a urinary leak was high, or a complex bladder neck reconstruction was performed. Routine postoperative cystograms were obtained. RESULTS: 208 patients underwent LRP with a RUVA. Data including cystogram was available for 206 patients. The overall rate of cystographic urine leak was 5.8 percent. A drain was placed in 51 patients. Of these, 8 (15.6 percent) had a postoperative leak on cystogram. Of the 157 undrained patients, urine leak was radiographically visible in 4 (2.5 percent). The higher leak rate in the drained vs. undrained cohort was statistically significant (p = 0.002). Twenty-four patients underwent pelvic lymph node dissection (8 drained, 16 undrained). Three undrained patients developed lymphoceles, which presented clinically on average 3 weeks postoperatively. There were no urinomas or hematomas in either group. CONCLUSIONS: Routine placement of a pelvic drain after LRP with a RUVA is not necessary, unless the anastomotic integrity is suboptimal intraoperatively. Experienced clinical judgment is essential and accurate in identifying patients at risk for postoperative leakage. When suspicion is low, omitting a drain does not increase morbidity.

Progression of laparoscopic radical prostatectomy: improved outcomes with the extraperitoneal approach and a running anastomosis.

PURPOSE: To compare the operative and perioperative outcomes of patients undergoing either a transperitoneal or an extraperitoneal laparoscopic radical prostatectomy (TLRP or ELRP) with either an interrupted or a running urethrovesical anastomosis (IUVA or RUVA). PATIENTS AND METHODS: From January 2003 through December 2004, 265 patients underwent LRP by one surgeon at the Lahey Clinic Medical Center. They were divided into three groups according to the operative approach (TLRP or ELRP) and the suture anastomosis (IUVA or RUVA): group 1 = TLRP and IUVA (N = 58; 21.6%), group 2 = TLRP and RUVA (N = 35; 13.1%), and group 3 = ELRP and RUVA (N = 172; 64.2%). RESULTS: Group 3 had statistically better outcomes, as judged by operative time (222, 191, and 170 minutes for groups 1, 2, and 3, respectively; P < 0.0001), postoperative analgesic use (39.6, 30.4, and 18.9 mg of narcotic; P < 0.0001), length of stay (3.76, 2.74 days, and 1.67 days; P < 0.0001), leak on postoperative cystogram (17.9%, 11.4%, and 3.5%; P = 0.001), and complication rate (32.8%, 11.4%, and 9.9%; P < 0.0001). The groups had similar estimated blood loss (168, 145, and 176 mL) and positive surgical-margin rates (15.5%, 14.3%, and 14.5%). CONCLUSIONS: We demonstrate improved surgical outcome for ELRP with RUVA in regard to operative time, analgesic use, length of stay, leak rate, and complication rate. Long-term follow-up will determine whether a difference exists in disease recurrence, continence, and erectile function.

Transperitoneal laparoscopic radical prostatectomy: descending technique.

Laparoscopic radical prostatectomy has evolved over the last decade to become a common treatment for clinically localized prostate cancer at specialized institutions. During that time, various technical modifications have been pioneered by groups throughout the world. We present our technique of transperitoneal laparoscopic radical prostatectomy through a descending approach. We believe that the transperitoneal approach affords better visual landmarks, a larger operative space, and a stable pneumoperitoneum. Our technique employs a five-trocar approach to the prostate. All dissection and suturing is performed intracorporeally. The perioperative morbidity and short-term efficacy are similar to those of the open procedure.

Laparoscopic radical cystectomy with continent urinary diversion (rectosigmoid pouch) performed completely intracorporeally: an intermediate functional and oncologic analysis.

OBJECTIVES: To present our experience with the first series of rectosigmoid pouch creation performed completely laparoscopically for continent urinary diversion after radical cystectomy to treat transitional cell carcinoma of the bladder. We evaluated the intermediate functional and oncologic outcomes. METHODS: Between April 2000 and January 2004, 20 patients underwent laparoscopic radical cystectomy with urinary diversion for transitional cell carcinoma at the Department of Urology, Charite Hospital, Campus Mitte. Of the 20 patients, 12 received a rectosigmoid pouch for urinary diversion. The procedures were performed completely laparoscopically, including free-hand laparoscopic suturing and in situ knot tying techniques. The mobilized specimens were removed in an endoscopy bag by way of the rectum or vagina. RESULTS: All operations were completed laparoscopically by two surgeons without conversion to open surgery. The median operating time was 485 minutes. One patient needed a blood transfusion of 2 U. All specimens had negative surgical margins. Two patients required reoperation. The median follow-up was 33 months. All patients were continent during the day, and 11 patients were continent at night. One patient developed unilateral hydronephrosis with loss of kidney function. No patient developed local recurrence, but 3 patients had systemic progression. Two of the three died of metastatic disease. CONCLUSIONS: This is the first series of laparoscopic radical cystectomy using an intracorporeal rectosigmoid pouch. Our functional data for continence and upper urinary tract obstruction were comparable with those of open rectosigmoid pouch studies. We were able to demonstrate an oncologic outcome similar to that achieved by the open surgical approach.

Laparoscopic radical prostatectomy--an analysis of factors affecting operating time.

OBJECTIVES: Although laparoscopic radical prostatectomy (LRP) is accomplished within 2 to 3 hours by experienced surgeons, less is known about the operating times (OTs) for recently trained surgeons or the influence of additional factors. As of November 2001 at our institution, two senior surgeons had each performed more than 100 cases of LRP and two junior surgeons had each performed fewer than 30. We prospectively studied the next 100 consecutive LRPs to assess the factors influencing the OT. METHODS: Transperitoneal LRPs were performed by two senior (n = 62) and two junior surgeons (n = 38) with random case assignment. We assessed body mass index, prostate size, prior abdominal surgery, androgen deprivation, surgeon experience, procedures in addition to LRP, lymph node dissection, nerve sparing, and sural nerve grafting as potential predictors of the OT. RESULTS: Prostate weight, androgen deprivation, and prior abdominal surgery did not significantly affect the OT, but grade 1 obesity increased the OT by an average of 38 minutes. The mean OT by surgeon experience was 214 minutes for seniors and 347 minutes for juniors (P <0.001). By procedure type, the OT ranged from 180 minutes for LRP only by seniors to 459 minutes for LRP plus lymph node dissection plus sural nerve grafting by juniors. Lymph node dissection and sural nerve grafting significantly increased the OT by 46 and 101 minutes, respectively, and nerve sparing did not. For each combination of procedures, seniors averaged significantly shorter times than did juniors. A multiple regression model with stepwise selection showed that prostate weight, sural nerve grafting, pelvic lymph node dissection, use of a surgical robot, and surgeon experience significantly affected the OT. CONCLUSIONS: The results of this prospective study of 100 cases of LRP showed that the OT for senior surgeons averaged 2 to 3 hours, but less experienced surgeons, and additional procedures, add significantly to the OT.

Positive margins after laparoscopic radical prostatectomy: a prospective study of 100 cases performed by 4 different surgeons.

OBJECTIVE: Laparoscopic radical prostatectomy (LRP) has been refined by experienced surgeons into a competitive treatment alternative for localized prostate cancer. Less is known, however, about the outcomes of "learning curve" cases from newly trained surgeons. We prospectively studied 100 cases of LRP performed by 2 senior and 2 junior surgeons and addressed the rates of positive margins-an important early endpoint of oncologic efficacy. METHODS: 100 consecutive cases of LRP were performed by two senior (n=62) and two junior surgeons (n=38) by a 5-port transperitoneal route. Whole-mount step-section prostate specimens were examined by Stanford protocol. RESULTS: Positive margins occured in 25% of cases: 18% for pT2a (2/11), 18% for pT2b (11/61), 45% for pT3a (10/22), and 50% for pT3b (2/4) (p=0.002 pT2 vs. pT3). By surgeon experience, the rates were 19% (12/62) for senior and 34% (13/38) for junior (p=0.04). However, in a multiple logistic regression analysis, only pathologic stage (p=0.083) and Gleason sum (p=0.0133) reached statistical significance, while surgeon experience did not (p=0.0992). CONCLUSION: Positive margin rates after laparoscopic radical prostatectomy are significantly influenced by pathologic stage and Gleason score, and are within the range reported from open series. The higher positive margin rate from junior surgeons, although not statistically significant, suggests the need for further study and continued mentoring during surgery and/or video review of cases to improve oncologic results.