Is patient outcome compromised during the initial experience with robot-assisted radical cystectomy? Results of 164 consecutive cases.

OBJECTIVE: • Robot-assisted radical cystectomy (RARC) remains controversial in terms of oncologic outcomes, especially during the initial experience. The purpose of this study was to evaluate the impact of initial experience of robotic cystectomy programs on oncologic outcomes and overall survival. PATIENTS AND METHODS: • Utilizing a prospectively maintained, single institution robotic cystectomy database, we identified 164 consecutive patients who underwent RARC since November 2005. • After stratification by age group, gender, pathologic T stage, lymph node status, surgical margin status, and sequential case number; we used chi-squared analyses to correlate sequential case number to operative time, surgical blood loss, lymph node yield, and surgical margin status. • We also addressed the relationship between complications and sequential case number. We then utilized Cox proportional hazard modeling and Kaplan-Meier survival analyses to correlate variables to overall mortality. RESULTS: • Sequential case number was not significantly associated with increased incidence of complications, surgical blood loss, or positive surgical margins (P= 0.780, P= 0.548, P= 0.545). Case number was, however, significantly associated with shorter operative time and mean number of lymph nodes retrieved (P < 0.001, P < 0.001). • Sequential case number was not significantly associated with survival; however, tumour stage, the presence of lymph node metastases, and positive surgical margins were significantly associated with death. • Although being the largest of its kind, this was a small study with short follow-up when compared to open cystectomy series. CONCLUSION: • Initial experience with RARC did not affect the incidence of positive surgical margins, operative/postoperative complications, or overall survival in a single-institution series.

Content validation of a novel robotic surgical simulator.

OBJECTIVE: • To assess the content validity of an early prototype robotic simulator. Minimally invasive surgery poses challenges for training future surgeons. The Robotic Surgical Simulator (RoSS) is a novel virtual reality simulator for the da Vinci Surgical System. PATIENTS AND METHODS: • Participants attending the 2010 International Robotic Urology Symposium were invited to experience RoSS. Afterwards, participants completed a survey regarding the appropriateness of the simulator as a teaching tool. RESULTS: • Forty-two subjects including surgeons experienced with robotics (n= 31) and novices (n= 11) participated in this study. • Eighty per cent of the entire cohort had an average of 4 years of experience with robot-assisted surgery. • Eleven (26%) novices lacked independent robot-assisted experience. The expert group comprised 17 (41%) surgeons averaging 881 (160-2200) robot-assisted cases. Experts rated the 'clutch control' virtual simulation task as a good (71%) or excellent (29%) teaching tool. • Seventy-eight per cent rated the 'ball place' task as good or excellent but 22% rated it as poor. • Twenty-seven per cent rated the 'needle removal' task as an excellent teaching tool, 60% rated it good and 13% rated it poor. • Ninety-one per cent rated the 'fourth arm tissue removal' task as good or excellent. • Ninety-four per cent responded that RoSS would be useful for training purposes. • Eighty-eight per cent felt that RoSS would be an appropriate training and testing format before operating room experience for residents. • Seventy-nine per cent indicated that RoSS could be used for privileging or certifying in robotic surgery. CONCLUSION: • Results based on expert evaluation of RoSS as a teaching modality illustrate that RoSS has appropriate content validity.

Validation of Robotic Surgery Simulator (RoSS).

Recent growth of daVinci Robotic Surgical System as a minimally invasive surgery tool has led to a call for better training of future surgeons. In this paper, a new virtual reality simulator, called RoSS is presented. Initial results from two studies - face and content validity, are very encouraging. 90% of the cohort of expert robotic surgeons felt that the simulator was excellent or somewhat close to the touch and feel of the daVinci console. Content validity of the simulator received 90% approval in some cases. These studies demonstrate that RoSS has the potential of becoming an important training tool for the daVinci surgical robot.

Status of robot-assisted radical cystectomy.

PURPOSE: Robot-assisted radical cystectomy (RARC) is an alternative approach for treatment of bladder cancer. We provide a critical review of the current status of RARC and pelvic lymph node dissection with a focus on feasibility, safety and oncological efficacy of the procedure. MATERIALS AND METHODS: The PubMed literature database was reviewed for RARC series that have been reported in the English language until the present time. Surgical technique, operative parameters, pathologic outcome, complications and quality of life were examined. RESULTS: RARC is progressing steadily. With nearly 500 published cases worldwide, RARC proves to be technically feasible and oncologically effective. It is associated with less blood loss, shorter hospital stay, and improved postoperative quality of life. Intracorporeal urinary diversion is still in the experimental phase, and effort is needed to make it technically easier and widely accepted. CONCLUSIONS: With the worldwide rapid spread of robot-assisted surgeries, RARC is evolving as a reliable minimally invasive alternative to standard open surgery. Awaiting long term oncological results, adequately powered prospective randomized trials comparing open, laparoscopic and robotic approaches are urgently needed.

Robot-assisted laparoscopic ureterolysis: case report and literature review of the minimally invasive surgical approach.

OBJECTIVES: To evaluate our case of robot-assisted ureterolysis (RU), describe our surgical technique, and review the literature on minimally invasive ureterolysis. METHODS: One patient managed with robot-assisted ureterolysis for idiopathic retroperitoneal fibrosis was identified. The chart was analyzed for demographics, operative parameters, and immediate postoperative outcome. The surgical technique was assessed and modified. Lastly, a review of the published literature on ureterolysis managed with minimally invasive surgery was performed. RESULTS: One patient underwent robot-assisted ureterolysis at our institution in 2 separate settings. Operative time (OR) decreased from 279 minutes to 191 minutes. Estimated blood loss (EBL) was less than 50 mL. The patient has been free of symptoms and both renal units are unobstructed. According to the published literature, 302 renal units underwent successful laparoscopic ureterolysis (LU), and 6 renal units underwent RU. There were 9 open conversions (all in LU). Mean OR in LU was 248 minutes for unilateral and 386 minutes for bilateral cases. In RU, mean OR was 220 minutes for unilateral and 390 minutes for bilateral cases. EBL averaged 200 mL in LU and 30 mL in RU. CONCLUSIONS: Our data reveal that robot-assisted ureterolysis is safe and feasible. Published data demonstrate the advantages of minimally invasive surgery.

Pediatric pyeloplasty: comparison of literature meta-analysis of laparoscopic and open techniques with open surgery at a single institution.

PURPOSE: We performed a meta-analysis of published series of laparoscopic and open pyeloplasty. We compared these data to open pyeloplasty at our institution using diuretic renography as the indicator for obstruction and postoperative success. MATERIALS AND METHODS: Laparoscopic studies included 19 series published between 1995 and 2007 comprising 346 kidneys. Open pyeloplasty studies included 9 series published between 1998 and 2007 comprising 486 kidneys. Data from our institution included records for 213 patients (224 kidneys). We defined reoperative intervention as unplanned placement of a nephrostomy tube or ureteral stent, balloon dilation or redo pyeloplasty. RESULTS: In the laparoscopic studies 171 cases (49%) were evaluated by preoperative and 137 (40%) by postoperative diuretic renography. Of patients undergoing postoperative diuretic renography 10 (7%) underwent reoperative intervention, including redo pyeloplasty (6, 4%), nephrostomy (3, 2%) and balloon dilation (1, 1%). In the open pyeloplasty studies performed elsewhere 165 cases (34%) were evaluated by preoperative and 230 (47%) by postoperative diuretic renography. Of patients undergoing postoperative diuretic renography redo pyeloplasty was required in 3 (1%). Of 224 cases managed by open pyeloplasty at our institution 215 (96%) had preoperative and postoperative diuretic renography data available. Of these patients 7 (3%) underwent reoperative intervention, including redo pyeloplasty (4, 2%), ureteral stent (2, 1%) and nephrostomy (1, 0.4%). CONCLUSIONS: Most publications do not confirm preoperative obstruction or, following laparoscopic or open pyeloplasty, postoperative success via diuretic renography. While not statistically significant, in the minority of studies with postoperative diuretic renography results the reoperative intervention rate and redo pyeloplasty rate following laparoscopy are approximately double those of open pyeloplasty.

Face validation of a novel robotic surgical simulator.

OBJECTIVES: To assess the face validity of Robotic Surgery Simulator (RoSS), a novel virtual reality training platform for the da Vinci Surgical System (DVSS). METHODS: Urologic surgeons, fellows, and residents attending the 2009 American Urologic Association Annual Meeting in April 2009 were invited to an orientation session with RoSS. Participants completed a questionnaire after orientation and two modules. RESULTS: Thirty participants including 24 surgeons and fellows experienced with robotic surgery and 6 robotic surgery novices participated in the study. Eighty percent participants had at least 4 years of experience with robotic surgery and 77% had performed an average of 340 cases on the DVSS as primary console surgeons. Subjects indicated that RoSS was realistically close to the DVSS console in terms of virtual simulation and instrumentation. Fifty-two percent of subjects rated RoSS somewhat close and 45% rated RoSS very close to the DVSS console. Thirty-seven percent rated RoSS pinch device somewhat close, and 47% very close to the DVSS. With regard to movement of the arms, 43% rated it somewhat close, 40% rated it very close, and 7% felt that it was just like the DVSS. Camera movement and clutch functions were rated not close (11%), somewhat close (57%), and very close (32%) to the DVSS. Data were further analyzed in terms of surgical volume. Thirty-eight percent of subjects had also tried the Mimic dV-Trainer robotic surgery simulator. CONCLUSIONS: RoSS provides opportunity for robot-assisted surgical training for future error-free surgery. Further validation will be necessary to assess RoSS and the application of specific modules for robot-assisted surgical training.

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.

Increasing age and treatment modality are predictors for subsequent diagnosis of bladder cancer following prostate cancer diagnosis.

PURPOSE: To determine the effect of prostate cancer therapy (surgery or external beam irradiation, or both or none) on the actuarial incidence of subsequent bladder cancer. METHODS AND MATERIALS: The Surveillance, Epidemiology, and End Results registry from 1973 to 2005 was analyzed. Treatment was stratified as radiotherapy, surgery, both surgery and adjuvant radiation, and neither modality. Brachytherapy was excluded. RESULTS: In all, 555,337 prostate carcinoma patients were identified; 124,141 patients were irradiated; 235,341 patients were treated surgically; 32,744 patients had both surgery and radiation; and 163,111 patients received neither modality. Bladder cancers were diagnosed in: 1,836 (1.48%) men who were irradiated (mean age, 69.4 years), 2,753 (1.09%) men who were treated surgically (mean age, 66.9 years); 683 (2.09%) men who received both modalities (mean age, 67.4 years), and 1,603 (0.98%) men who were treated with neither modality (mean age, 71.8 years). In each treatment cohort, Kaplan-Meier analyses showed that increasing age (by decade) was a significant predictor of developing bladder cancer (p < 0.0001). Incidence of bladder cancer was significantly different for either radiation or surgery alone versus no treatment, radiation versus surgery alone, and both surgery and radiation versus either modality alone (p < 0.0001). On multivariate analysis, age and irradiation were highly significant predictors of being diagnosed with bladder cancer. CONCLUSIONS: Following prostate cancer, increasing age and irradiation were highly significant predictors of being diagnosed with bladder cancer. While use of radiation increased the risk of bladder cancer compared to surgery alone or no treatment, the overall incidence of subsequent bladder cancer remained low. Routine bladder cancer surveillance is not warranted.

Can image-based virtual reality help teach anatomy?

OBJECTIVE: To assess the utilization of a novel virtual reality robotic surgical simulator (RoSS) in surgical anatomy training and pattern recognition. STUDY DESIGN: Ten surgical trainees (medical students and residents) were recruited to participate in a study that evaluated the efficacy of a robotic simulator in anatomy training. The subjects were divided into two groups of five individuals each. Each participant received a syllabus consisting of line diagrams and color pictures of the human anatomy. All participants were later tested on identifying the same five anatomical landmarks from photographs from actual laparoscopic procedures. Group I studied the syllabus and took the test. Group II similarly studied the syllabus, but were trained on the RoSS system using cognitive skill sets and then took the same test. Group II were asked to complete a posttest survey. RESULTS: Mean time to complete the test was 142.8 seconds for group I and 118.4 seconds for group II. Mean number of errors committed by the group trained on RoSS was 0.4 out of 5, whereas the group that did not undergo training on RoSS committed 1.7 out of 5. The mean number of correct answers given by group I was 2.9 out of 5, whereas group II answered 4.2 out 5 correctly. All results were statistically significant. The subjects rated the anatomy module helpful, with a mean rating of 3.6 out of 5. CONCLUSIONS: RoSS is an effective tool in anatomy training. Further testing is underway to illustrate its important role in medical education and robotic surgical training.

Three-month-old boy with juvenile granulosa cell tumor of testis and ossifying renal tumor of infancy.

We describe a 3-month-old male infant who presented with gross hematuria and was found to have a renal mass and a testicular mass representing these two entities. This is the first case report of these two lesions presenting concomitantly.