Robot-assisted approach to 'W'-configuration urinary diversion: a step-by-step technique.

OBJECTIVE: To describe a detailed step-by-step approach of our technique for robot-assisted intracorporeal 'W'-configuration orthotopic ileal neobladder. PATIENTS AND METHODS: Five patients underwent robot-assisted radical cystectomy (RARC), extended pelvic lymph node dissection and intracorporeal neobladder (ICNB). ICNB was divided into six key steps to facilitate and enable a detailed analysis and auditing of the technique. No conversion to open surgery was required. Timing for each step was noted. All patients had at least 3 months of follow-up. RESULTS: The mean age was 57 years. The mean overall console and diversion times were 357 and 193 min, respectively. None of the patients had any evidence of residual disease after RARC. Four of the five patients had complications; three developed fevers due to urinary tract infections (one required readmission), and one developed myocardial infarction and required coronary angiography and stenting. Looking at the timing for the individual steps, bowel detubularisation and construction of the posterior plate were consistently the longest among the key steps (average 46 min, 13% of the overall operative time), followed by uretero-ileal anastomosis (37 min, 10%), neobladder-urethral anastomosis (23 min, 6%), and identification and fixation of the bowel (26 min, 7%). CONCLUSION: We described our step-by-step technique and initial perioperative outcomes of our first five ICNBs with 'W' configuration.

Tips and tricks to robot-assisted radical cystectomy and intracorporeal diversion.

PURPOSE OF REVIEW: To summarize the fundamental principles for technique of robot-assisted radical cystectomy (RARC) based on current peer reviewed literature. Also provide most recent evidence for the efficacy of RARC and Intracorporeal Ileal Conduit (ICIC). RECENT FINDINGS: Technical tricks have increased the efficiency of RARC and ICIC diversion. Perioperative and short-term outcomes have demonstrated that RARC is an acceptable alternative to open radical cystectomy. Acceptable positive surgical margin rates, thorough extended lymph node dissection based on tenets of oncological principles and acceptable short-term oncologic outcomes have been reported. Learning curve towards safe incorporation of intracorporeal urinary diversion and its evolution are presented. SUMMARY: The technical tips and tricks have led to evolution of technique translating into improved surgical outcomes. RARC is a well tolerated and effective alternative to open cystectomy and urinary diversion. Intracorporeal urinary diversion is the next challenge on the horizon with an acceptable learning curve and outcomes; this evolution will lead to improvement in quality of life after this morbid surgical procedure.

Novel knot tying technique for robot-assisted surgery.

Robot-assisted surgery has seen significant advancements in recent years, with dedicated training opportunities to acquire adequate skills. With improved degree of rotation and movement offered by the robot arm, newer techniques of knot tying need to be developed. Here we present a novel method of knot tying to help place a secure knot, especially with short suture length.

Rapid communication: robot-assisted anterior exenteration: technique and initial series.

BACKGROUND AND PURPOSE: The feasibility of robot-assisted anterior exenteration (RAAE) in women has been reported but not well established. We report our experience with seven patients, providing perioperative data, hospital course, and immediate oncologic outcomes. PATIENTS AND METHODS: From November 2005 to June 2006, seven consecutive patients with a mean age of 70 years (range 59-82 years) underwent RAAE for bladder cancer. Urinary diversion consisted of an ileal conduit in six patients and neobladder in one. The mean body mass index and ASA scores were 25 (range 20-36) and 2 (range 2-3), respectively. Data were collected prospectively on intraoperative performance, oncologic status, and postoperative outcomes. RESULTS: The mean operative times for RAAE, pelvic lymph-node dissection, and ileal-conduit creation were 227 minutes (range 142-350 minutes), 48 minutes (range 35-80 minutes), and 132 minutes (range 80-255 minutes), respectively. The time needed for neobladder formation was 3 hours. The time required for anastomosis between the neobladder and the urethra with robotic assistance was 1 hour and 43 minutes, including time for closure of the mini-incision, redocking, and port placement. No case was converted to open surgery. All the surgical specimens were removed vaginally. There were no intraoperative complications or need for intraoperative blood transfusions. The only postoperative complication was an episode of pyelonephritis, which was managed successfully with antibiotics. The average times to return to normal and strenuous activity were 3.7 and 7.3 weeks, respectively. Final pathology examination revealed T(0)N(0), TisN(0), T(1)N(0), T(2b)N(0), T(3a)N(0), T(3a)N(1), and T(4)N(3) disease. Six patients had negative surgical margins, whereas the patient with T(4)N(3) disease had positive vaginal margins. CONCLUSION: Robot-assisted anterior exenteration can be offered safely to women. The long-term oncologic outcomes and experience of others will define its place in urologic oncology.

Surgical competency for urethrovesical anastomosis during robot-assisted radical prostatectomy: development and validation of the robotic anastomosis competency evaluation.

OBJECTIVE: To develop and validate an assessment tool for the performance of urethrovesical anastomosis (UVA). METHODS: A multicenter, prospective, observational study was conducted in 2 phases. Phase 1, development and content validation, used a panel of 5 experienced robotic surgeons to develop a 6-domain scoring system, Robotic Anastomosis Competence Evaluation (RACE), to assess technical skills for performing UVA. Phase 2, construct validation and reliability, used 5 blinded experienced robotic surgeons to rate UVA recordings of expert, advanced beginner, and novice groups. Content validation index was determined to report consensus in phase 1. Phase 2 involved comparison of RACE scores among the 3 groups. Wilcoxon rank-sum tests were used to compare RACE scores. RESULTS: Two rounds of Delphi methodology achieved consensus on language and content of RACE. Eight experts, 10 advanced beginners, and 10 novice robotic surgeons participated in the validation study. The overall score for the expert group (27.3) was higher than that of the advanced beginner (19.5; P = .04) and novice groups (13.6; P = .001). The advanced beginner and novice groups differed in overall scores (P = .03). CONCLUSION: RACE allows evaluation of surgical competence to perform UVA for robot-assisted radical prostatectomy, when using an inanimate model.

Robot-assisted intracorporeal ileal conduit: Marionette technique and initial experience at Roswell Park Cancer Institute.

OBJECTIVES: To present our technique and initial experience with patients who underwent robot-assisted intracorporeal creation of ileal conduit and to compare them with patients who underwent extracorporeal ileal diversion after robot-assisted radical cystectomy. METHODS: Twenty-six patients diagnosed with invasive transitional cell carcinoma of the bladder underwent a robot-assisted radical cystectomy with bilateral extended pelvic lymphadenectomy with ileal conduit diversion. Total intracorporeal ileal conduit creation was performed in the last 13 patients. Operative data and short-term outcomes between the 2 groups were assessed. The novel surgical technique for intracorporeal ileal conduit will be presented. RESULTS: The intracorporeal group (IC) included 2 female and 11 male patients (mean age 71 years). The extracorporeal group (EC) included 4 female and 9 male patients (mean age 66 years). No significant differences were noted between the groups in terms of patient age, BMI, sex, prior surgery, or pathologic stage. Overall operative time and intraoperative complications were similar. No significant differences were noted between the 2 groups in terms of diversion time or estimated blood loss. There were 4 complications recorded in IC patients, including nonspecific colitis, small bowel obstruction requiring exploratory laparotomy with lysis of adhesions, a urine leak that eventually resolved but required a temporary nephrostomy tube, and a fever of unknown origin that resolved without intervention. CONCLUSIONS: Robot-assisted intracorporeal ileal conduit can be accomplished safely with acceptable operative times even during early experience. Larger series with favorable results will be required to add this new paradigm to minimally invasive surgery for bladder cancer.