Implementation of a multimodal opioid-sparing enhanced recovery pathway for robotic-assisted radical prostatectomy.

The purpose of the study is to evaluate the impact of a multimodal Enhanced Recovery After Surgery (ERAS) protocol on perioperative opioid consumption and hospital length of stay (LOS) after robotic-assisted radical prostatectomy (RARP). We compared the first 176 patients enrolled in the protocol (ERAS group) with the previous 176 patients (non-ERAS group) at a single quaternary institution from December 2017 to June 2019. The ERAS protocol included a multimodal opioid-sparing regimen utilizing acetaminophen, gabapentin, celecoxib, and liposomal bupivacaine. Demographic data, co-morbidities, post-operative pain scores, post-operative opiate consumption measured by morphine milligram equivalents (MME), operating time, and LOS were collected. The two groups were compared using chi-squared, Fisher exact, or Student t tests as appropriate. Multivariable logistic regression analysis was performed to identify predictors of prolonged LOS (> 1 day). The ERAS and non-ERAS groups were equivalent in terms of baseline characteristics and pathological data. The ERAS group had lower post-operative pain scores, post-operative opiate consumption (MME 15 vs. 46, p < 0.01), and LOS (1.2 vs. 1.7 days, p < 0.01) compared to the non-ERAS group. Only 22% in the ERAS cohort had a prolonged LOS compared to 39% of the non-ERAS group (p < 0.01). The ERAS protocol was a negative predictor of prolonged LOS on multivariable logistic regression analysis (odds ratio 0.39, 95% confidence interval 0.22-0.70, p < 0.01). A limitation of this study is its single-center retrospective design. The implementation of a multimodal opioid-sparing ERAS protocol was associated with improved pain control, reduced perioperative opioid usage, and shorter LOS after RARP.

Robotic-assisted laparoscopic repair of ureteral injury: an evidence-based review of techniques and outcomes.

INTRODUCTION: Iatrogenic ureteral injuries represent a common surgical problem encountered by practicing urologists. With the rapidly expanding applications of robotic-assisted laparoscopic surgery, ureteral reconstruction has been an important field of recent advancement. This collaborative review sought to provide an evidence-based analysis of the latest surgical techniques and outcomes for robotic-assisted repair of ureteral injury. EVIDENCE ACQUISITION: A systematic review of the literature up to December 2017 using PubMed/Medline was performed to identify relevant articles. Those studies included in the systematic review were selected according to Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. Additionally, expert opinions were included from study authors in order to critique outcomes and elaborate on surgical techniques. A cumulative outcome analysis was conducted analyzing comparative studies on robotic versus open ureteral repair. EVIDENCE SYNTHESIS: Thirteen case series have demonstrated the feasibility, safety, and success of robotic ureteral reconstruction. The surgical planning, timing of intervention, and various robotic reconstructive techniques need to be tailored to the specific case, depending on the location and length of the injury. Fluorescence imaging can represent a useful tool in this setting. Recently, three studies have shown the feasibility and technical success of robotic buccal mucosa grafting for ureteral repair. Soon, additional novel and experimental robotic reconstructive approaches might become available. The cumulative analysis of the three available comparative studies on robotic versus open ureteral repair showed no difference in operative time or complication rate, with a decreased blood loss and hospital length of stay favoring the robotic approach. CONCLUSIONS: Current evidence suggests that the robotic surgical platform facilitates complex ureteral reconstruction in a minimally invasive fashion. High success rates of ureteral repair using the robotic approach mirror those of open surgery, with the additional advantage of faster recovery. Novel techniques in development and surgical adjuncts show promise as the role of robotic surgery evolves.

Evolution of robot-assisted orthotopic ileal neobladder formation: a step-by-step update to the University of Southern California (USC) technique.

OBJECTIVE: To describe our, step-by-step, technique for robotic intracorporeal neobladder formation. PATIENTS AND METHODS: The main surgical steps to forming the intracorporeal orthotopic ileal neobladder are: isolation of 65 cm of small bowel; small bowel anastomosis; bowel detubularisation; suture of the posterior wall of the neobladder; neobladder-urethral anastomosis and cross folding of the pouch; and uretero-enteral anastomosis. Improvements have been made to these steps to enhance time efficiency without compromising neobladder configuration. RESULTS: Our technical improvements have resulted in an improvement in operative time from 450 to 360 min. CONCLUSION: We describe an updated step-by-step technique of robot-assisted intracorporeal orthotopic ileal neobladder formation.

Outpatient Robotic Radical Prostatectomy: Matched-Pair Comparison with Inpatient Surgery.

PURPOSE: To evaluate our initial experience with outpatient robotic radical prostatectomy (RRP) and to prospectively compare outcomes with an inpatient RRP group. MATERIALS AND METHODS: We conducted a prospective study on 30 carefully selected, motivated patients consenting for outpatient RRP (2011-2013). Inclusion criteria comprised age<65 years, American Society of Anesthesiologists score<3, body mass index<35 kg/m2, localized prostate cancer, and primary treatment. Postoperatively, close monitoring was conducted by telephone for the first 24 hours, with routine follow-up subsequently. This outpatient group was prospectively matched 1:1 with a concurrent inpatient RRP group who satisfied inclusion criteria for, but did not undergo, outpatient RRP. Validated questionnaires were administered prospectively to determine patient satisfaction and functional outcomes. RESULTS: All outpatient RRP procedures were performed effectively. Twenty-six patients (87%) were discharged the same day of surgery, four stayed overnight for various reasons. On comparing outpatient and inpatient groups, there were no significant demographic or perioperative differences, except for shorter hospital stay (14 hours vs 44 hours, p<0.01). In both groups, 92% of patients were completely continent (no pads) at 2 months follow-up. Time to complete continence in the outpatient and inpatient groups was 32 days vs 43 days (p=0.09). Validated questionnaires revealed both groups were comparable as regards patient/family satisfaction, days of narcotic usage, days to return to work, and days to feeling 100% recovered. CONCLUSION: Our initial experience with outpatient RRP is promising. Outpatient RRP is associated with excellent patient satisfaction and functional outcomes comparable with inpatient RRP. Patient motivation and preoperative counseling are vital for success.

Robotic unclamped "minimal-margin" partial nephrectomy: ongoing refinement of the anatomic zero-ischemia concept.

BACKGROUND: Anatomic partial nephrectomy (PN) techniques aim to decrease or eliminate global renal ischemia. OBJECTIVE: To report the technical feasibility of completely unclamped "minimal-margin" robotic PN. We also illustrate the stepwise evolution of anatomic PN surgery with related outcomes data. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective analysis of 179 contemporary patients undergoing anatomic PN at a tertiary academic institution between October 2009 and February 2013. Consecutive consented patients were grouped into three cohorts: group 1, with superselective clamping and developmental-curve experience (n = 70); group 2, with superselective clamping and mature experience (n = 60); and group 3, which had completely unclamped, minimal-margin PN (n = 49). SURGICAL PROCEDURE: Patients in groups 1 and 2 underwent superselective tumor-specific devascularization, whereas patients in group 3 underwent completely unclamped minimal-margin PN adjacent to the tumor edge, a technique that takes advantage of the radially oriented intrarenal architecture and anatomy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcomes assessed the technical feasibility of robotic, completely unclamped, minimal-margin PN; short-term changes in estimated glomerular filtration rate (eGFR); and development of new-onset chronic kidney disease (CKD) stage >3. Secondary outcome measures included perioperative variables, 30-d complications, and histopathologic outcomes. RESULTS AND LIMITATIONS: Demographic data were similar among groups. For similarly sized tumors (p = 0.13), percentage of kidney preserved was greater (p = 0.047) and margin width was narrower (p = 0.0004) in group 3. In addition, group 3 had less blood loss (200, 225, and 150ml; p = 0.04), lower transfusion rates (21%, 23%, and 4%; p = 0.008), and shorter hospital stay (p = 0.006), whereas operative time and 30-d complication rates were similar. At 1-mo postoperatively, median percentage reduction in eGFR was similar (7.6%, 0%, and 3.0%; p = 0.53); however, new-onset CKD stage >3 occurred less frequently in group 3 (23%, 10%, and 2%; p = 0.003). Study limitations included retrospective analysis, small sample size, and short follow-up. CONCLUSIONS: We developed an anatomically based technique of robotic, unclamped, minimal-margin PN. This evolution from selective clamped to unclamped PN may further optimize functional outcomes but requires external validation and longer follow-up. PATIENT SUMMARY: The technical evolution of partial nephrectomy surgery is aimed at eliminating global renal damage from the cessation of blood flow. An unclamped minimal-margin technique is described and may offer renal functional advantage but requires long-term follow-up and validation at other institutions.

Robotic Transabdominal Control of the Suprahepatic, Infradiaphragmatic Vena Cava to Enable Level 3 Caval Tumor Thrombectomy: Pilot Study in a Perfused-Cadaver Model.

PURPOSE: To develop a robotic technique for exclusively transabdominal control of the suprahepatic, infradiaphragmatic inferior vena cava (IVC) to enable level 3 IVC tumor thrombectomy. MATERIALS AND METHODS: Robotic technique was developed in three fresh, perfused-model cadavers. Preoperatively, inflow (right jugular vein) and outflow (left femoral vein) cannulae were inserted and connected to a centrifugal pump to establish a 10 mmHg pressure in the IVC for the water-perfused cadaver model. Using a five-port transperitoneal robotic approach, the falciform ligament was detached from the anterior abdominal wall toward its junction with the diaphragm and tautly retracted caudally; this adequately retracted the liver caudally as well. Triangular and coronary ligaments were incised, allowing ready visualization of suprahepatic/infradiaphragmatic IVC and right/left main hepatic veins. Under direct robotic visualization, IVC was circumferentially mobilized, vessel-looped, and controlled. RESULTS: All three robotic procedures were successfully completed transabdominally. Average robotic time to control the suprahepatic IVC was 37 minutes; in each case, the suprahepatic IVC was circumferentially controlled with a vessel-loop. There were no intraoperative complications. Length of the mobilized suprahepatic IVC measured between 2 and 3 cm. Right and left suprahepatic veins were clearly visualized in each case. Necropsy revealed no intra-abdominal/intrathoracic visceral or vascular injuries to the suprahepatic IVC, bilateral hepatic veins, or tributaries. CONCLUSIONS: We developed a novel robotic technique for transabdominal control of the suprahepatic infradiaphragmatic IVC in a perfused human cadaver model. This approach may extend the application of advanced robotic techniques for the performance of major vena caval, hepatic, and level 3 IVC renal tumor thrombus surgery.

Port Placement and Docking for Robotic Surgery: The University of Southern California Approach.

PURPOSE: To describe our approach for port placement and robot docking for pelvic and kidney surgery (KS). PATIENTS AND METHODS: We use a four-arm robotic approach and a 5 to 6 port placement consisting of: One 12-mm camera port, three 8-mm robotic ports, and one to two assistant ports. For radical prostatectomy, the working robotic ports run parallel below the level of the umbilicus. Radical cystectomy ports are more cephalad and above the level of the umbilicus. For transperitoneal KS, two bariatric robotic ports are used, aiming for an equilateral triangle configuration. With retroperitoneal (RN) KS, a balloon dilator and balloon port create the RN space; bariatric ports comprise the most anterior and posterior ports. RESULTS: This technique has been used since 2010 on more than 2370 robotic urologic cases. To date, no procedure has needed patient or robot positioning while maintaining fourth arm functionality with minimal robotic arm clashing. CONCLUSIONS: Our approach of port placement and robot docking is reproducible and feasible for pelvic surgical procedures and KS.

Robotic implantation of biodegradable regenerative urinary conduit: experimental study.

PURPOSE: To determine the feasibility and develop a robotic technique for intracorporeal implantation of a biodegradable tubular scaffold seeded with adipose-sourced smooth muscle cells (Neo-Urinary-Conduit) that, when implanted as a conduit for urinary diversion, facilitates regeneration of native-like neourinary tissue. MATERIALS AND METHODS: Robotic NUC implantation was performed in two fresh male cadavers. The greater omentum was widely detached from the greater curvature of the stomach, in preparation for final wrapping of the conduit. Bilateral ureters were mobilized for implantation. The NUC, with two precreated ureteral openings, was inserted into the abdomen. Bilateral, stented uretero-NUC anastomoses were created. The NUC was circumferentially wrapped with the predissected omentum, exteriorized through the abdominal wall, and maturated. RESULTS: Both procedures were successfully completed intracorporeally. Operative time for NUC implantation was 90 and 100 minutes, respectively. Examination of gross anatomy showed no injury to other organs. There was no omental kinking, rotation, eversion, or stripping from the NUC. Bilateral stents were confirmed to be in situ with the proximal coil in the kidney. Uretero-NUC anastomoses and omentum were tension free. The entire NUC, including its distal edge and posterior aspect, was circumferentially wrapped 360 degrees. CONCLUSION: We demonstrated the feasibility and developed a robotic technique for intracorporeal implantation of a biodegradable regenerative urinary conduit. This study serves as the foundation for the robotic surgical technique before the clinical application.

Robotic radical cystectomy and intracorporeal urinary diversion: The USC technique.

INTRODUCTION: Radical cystectomy is the gold-standard treatment for muscle-invasive and refractory nonmuscle-invasive bladder cancer. We describe our technique for robotic radical cystectomy (RRC) and intracorporeal urinary diversion (ICUD), that replicates open surgical principles, and present our preliminary results. MATERIALS AND METHODS: Specific descriptions for preoperative planning, surgical technique, and postoperative care are provided. Demographics, perioperative and 30-day complications data were collected prospectively and retrospectively analyzed. Learning curve trends were analyzed individually for ileal conduits (IC) and neobladders (NB). SAS(®) Software Version 9.3 was used for statistical analyses with statistical significance set at P < 0.05. RESULTS: Between July 2010 and September 2013, RRC and lymph node dissection with ICUD were performed in 103 consecutive patients (orthotopic NB=46, IC 57). All procedures were completed robotically replicating the open surgical principles. The learning curve trends showed a significant reduction in hospital stay for both IC (11 vs. 6-day, P < 0.01) and orthotopic NB (13 vs. 7.5-day, P < 0.01) when comparing the first third of the cohort with the rest of the group. Overall median (range) operative time and estimated blood loss was 7 h (4.8-13) and 200 mL (50-1200), respectively. Within 30-day postoperatively, complications occurred in 61 (59%) patients, with the majority being low grade (n = 43), and no patient died. Median (range) nodes yield was 36 (0-106) and 4 (3.9%) specimens had positive surgical margins. CONCLUSIONS: Robotic radical cystectomy with totally ICUD is safe and feasible. It can be performed using the established open surgical principles with encouraging perioperative outcomes.

Flank muscle volume changes after open and laparoscopic partial nephrectomy.

PURPOSE: To determine the occurrence of flank symptoms, flank muscle atrophy, bulge, and hernia formation after open and laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Our prospective Institutional Review Board-approved database was queried to identify 50 consecutive patients who were treated with open partial nephrectomy (OPN) and 50 consecutive patients who were treated with LPN between September 2006 and May 2008. Study patients had: Solitary clinical T1 renal tumor, preoperative and ≥6 month postoperative CT scan performed at our institution, and a confirmed renal-cell carcinoma on the final pathology report. Patients with previous abdominal surgery and neuromuscular disorders were excluded. Oncocare software was used to measure abdominal wall musculature on preoperative and postoperative CT scan. Bilateral flanks were compared for muscle volume, bulge, and hernia. Patients were administered a phone questionnaire to assess postoperative flank symptoms. RESULTS: No statistical significant difference was found in the demographics between the two groups. Median age (range) was 59.9 years (20.6-80.7) in the OPN group and 57.5 years (25-78) in the LPN group (P=0.89). Median (range) body mass index and American Society of Anesthesiologists scores were similar between the two groups. On CT scans, median percent variation (range) in abdominal wall muscle volume was significantly greater in the OPN group: -1.03% (-31.4-1.5) vs-0.39% (-5.2-1.8) (P=0.006). The median extent of flank bulge on CT scans (range) was also greater in the OPN group: 0.75 cm (-1.9-7.6) vs 0 cm (-2.7-2.8) (P=0.0004). The OPN group was also more symptomatic, including paresthesia 48% vs 8% (P=0.0053); numbness 44% vs 0% (P=0.002); and flank bulge 57% vs 12% (P=0.007). CONCLUSIONS: Minimally invasive partial nephrectomy has lesser deleterious impact on flank muscle volume compared with OPN with fewer symptoms of flank bulge, paresthesia, and numbness.

Renal tumor contact surface area: a novel parameter for predicting complexity and outcomes of partial nephrectomy.

BACKGROUND: The contact surface area (CSA) of a tumor with adjacent renal parenchyma may determine the complexity and thus the perioperative outcomes of partial nephrectomy (PN). OBJECTIVE: We devised a novel imaging parameter, renal tumor CSA, and correlate it with perioperative outcomes in patients undergoing PN. DESIGN, SETTING, AND PARTICIPANTS: Of 200 patients undergoing PN for a tumor (January 2010 to August 2011), 162 had renal protocol computed tomography scanning data available. CSA was calculated using image-rendering software (Synapse 3D, Fujifilm), and interobserver variability was determined between three independent observers. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: CSA was correlated to baseline demographics and perioperative outcomes as a continuous and categorical variable using multivariable logistic regression analysis. The ability of CSA to predict adverse perioperative events was compared with demographic factors and nephrometry scoring systems. RESULTS AND LIMITATIONS: The mean tumor size was 3.1cm; CSA was 18.3 cm(2). CSA ≥20 cm(2) correlated with adverse tumor characteristics (greater tumor size, volume, and complexity) and perioperative outcomes (more parenchymal volume loss, blood loss, and complications) compared with CSA <20 cm(2). On multivariable logistic regression, CSA independently predicted operative time, complications, hospital stay, and renal functional outcomes. This predictive ability of CSA was superior to the other parameters evaluated. CONCLUSIONS: CSA is a novel imaging parameter that quantifies the CSA of renal tumor with adjacent parenchyma. Our preliminary data indicate that CSA correlates with PN outcomes. If validated externally in a larger cohort, CSA could be incorporated into future versions of nephrometry scoring systems. PATIENT SUMMARY: In this study we outline the method of calculating the contact surface area (CSA) of renal tumors with the surrounding normal kidney using image-rendering software. We found that CSA correlates with a number of important surgical outcomes including operative time, loss of renal function, and complications.

Robotic partial nephrectomy with superselective versus main artery clamping: a retrospective comparison.

BACKGROUND: Concerns have been raised regarding partial nephrectomy (PN) techniques that do not occlude the main renal artery. OBJECTIVE: Compare the perioperative outcomes of superselective versus main renal artery control during robotic PN. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of 121 consecutive patients undergoing robotic PN using superselective control (group 1, n=58) or main artery clamping (group 2, n=63). INTERVENTION: Group 1 underwent tumor-specific devascularization, maintaining ongoing arterial perfusion to the renal remnant at all times. Group 2 underwent main renal artery clamping, creating global renal ischemia. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Perioperative and functional data were evaluated. The Pearson chi-square or Fisher exact and Wilcoxon rank sum tests were used. RESULTS AND LIMITATIONS: All robotic procedures were successful, all surgical margins were negative, and no kidneys were lost. Compared with group 2 tumors, group 1 tumors were larger (3.4 vs 2.6cm, p=0.004), more commonly hilar (24% vs 6%, p=0.009), and more complex (PADUA 10 vs 8, p=0.009). Group 1 patients had longer median operative time (p<0.001) and transfusion rates (24% vs 6%, p<0.01) but similar estimated blood loss (200 vs 150ml), perioperative complications (15% vs 13%), and hospital stay. Group 1 patients had less decrease in estimated glomerular filtration rate at discharge (0% vs 11%, p=0.01) and at last follow-up (11% vs 17%, p=0.03). On computed tomography volumetrics, group 1 patients trended toward greater parenchymal preservation (95% vs 90%, p=0.07) despite larger tumor size and volume (19 vs 8ml, p=0.002). Main limitations are the retrospective study design, small cohort, and short follow-up. CONCLUSIONS: Robotic PN with superselective vascular control enables tumor excision without any global renal ischemia. Blood loss, complications, and positive margin rates were low and similar to main artery clamping. In this initial developmental phase, limitations included more perioperative transfusions and longer operative time. The advantage of superselective clamping for better renal function preservation requires validation by prospective randomized studies. PATIENT SUMMARY: Preserving global blood flow to the kidney during robotic partial nephrectomy (PN) does not lead to a higher complication rate and may lead to better postoperative renal function compared with clamped PN techniques.

Transvesical robotic simple prostatectomy: initial clinical experience.

BACKGROUND: Despite significant developments in transurethral surgery for benign prostatic hyperplasia (BPH), simple prostatectomy remains an excellent option for patients with large glands. OBJECTIVE: To describe our technique of transvesical robotic simple prostatectomy (RSP). DESIGN, SETTING, AND PARTICIPANTS: From May 2011 to April 2013, 25 patients underwent RSP. SURGICAL PROCEDURE: We performed RSP using our technique. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Baseline demographics, pathology data, perioperative complications, 90-d complications, and functional outcomes were assessed. RESULTS AND LIMITATIONS: Mean patient age was 72.9 yr (range: 54-88), baseline International Prostate Symptom Score (IPSS) was 23.9 (range: 9-35), prostate volume was 149.6 ml (range: 91-260), postvoid residual (PVR) was 208.1 ml (range: 72-800), maximum flow rate (Qmax) was 11.3 ml/s, and preoperative prostate-specific antigen was 9.4 ng/ml (range: 1.9-56.3). Eight patients were catheter dependent before surgery. Mean operative time was 214 min (range: 165-345), estimated blood loss was 143 ml (range: 50-350), and the hospital stay was 4 d (range: 2-8). There were no intraoperative complications and no conversions to open surgery. Five patients had a concomitant robotic procedure performed. Early functional outcomes demonstrated significant improvement from baseline with an 85% reduction in mean IPSS (p<0.0001), an 82.2% reduction in mean PVR (p=0.014), and a 77% increase in mean Qmax (p=0.20). This study is limited by small sample size and short follow-up period. One patient had a urinary tract infection; two had recurrent hematuria, one requiring transfusion; one patient had clot retention and extravasation, requiring reoperation. CONCLUSIONS: Our technique of RSP is safe and effective. Good functional outcomes suggest it is a viable option for BPH and larger glands and can be used for patients requiring concomitant procedures. PATIENT SUMMARY: We describe the technique and report the initial results of a series of cases of transvesical robotic simple prostatectomy. The procedure is both feasible and safe and a good option for benign prostatic hyperplasia with larger glands.

Management of large median and lateral intravesical lobes during robot-assisted radical prostatectomy.

PURPOSE: To describe a technique to manage large intravesical prostate lobes (IVPL) during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: We used a "rescue stitch" to retract large IVPLs anteriorly out of the bladder lumen. This stitch is a 6-inch long 0-polyglactin suture on a CT-1 needle with a Hem-o-lok clip tied to the tail end. We deployed this through the IVPL from distal to proximal allowing the Hem-o-lok clip to sit against the lobe's distal aspect. The suture is grasped and pulled toward the symphysis, delivering the IVPL from the bladder lumen providing an unobstructed view of the posterior bladder neck (BN). RESULTS: This was performed in 15 patients. Median (range) time to prepare and deploy the stitch(es) was 2 (0.5-3) and 5 (2-15) minutes, respectively. Five patients required >1 stitch. BN reconstruction was not needed. No patient had a positive margin at the BN. CONCLUSIONS: Deploying a stitch allows anterior dynamic retraction of the prostate, facilitating the dissection of the posterior BN.

Minimally invasive partial nephrectomy for single versus multiple renal tumors.

PURPOSE: We report the perioperative outcomes of robotic/laparoscopic partial nephrectomy for multiple tumors at a single operative session. Outcomes were compared with those of a matched pair cohort treated with partial nephrectomy for a single renal tumor. MATERIALS AND METHODS: We retrospectively reviewed a prospectively maintained database from 2001 to 2010 and identified 33 patients who underwent partial nephrectomy for multiple tumors. They were matched 1 to 1 with 33 patients treated with partial nephrectomy for a single tumor. The multiple and single groups were matched for dominant tumor size (3.2 and 3.3 cm, p = 0.61), patient age (60 and 57 years, p = 0.59) and baseline estimated glomerular filtration rate (79.7 and 91.8 ml per minute/1.73 m(2), p = 0.11), respectively. RESULTS: A total 114 tumors were excised, including 81 in the multiple cohort. There was a median of 2 tumors per kidney (range 2 to 6). In the multiple and single tumor groups estimated blood loss (250 and 235 ml, p = 0.46) and warm ischemia time (19 and 30 minutes, respectively, p = 0.18) were similar. Median operative time (300 vs 217 minutes, p = 0.002) and hospital stay (3 vs 1 days, p = 0.005) were longer in the multiple group. There were 2 conversions to laparoscopic radical nephrectomy per group. Overall, complications developed in 11 (33%) vs 7 patients (21%) treated with partial nephrectomy for multiple vs single tumors (p = 0.40). Median estimated glomerular filtration rate at discharge home was 62.8 vs 67.6 ml per minute/1.73 m(2) in the multiple vs single tumor groups (p = 0.53). Histology confirmed malignancy in 82% and 67% of patients, respectively (p = 0.26). One recurrent tumor in the multiple group had a focal positive margin. CONCLUSIONS: Robotic/laparoscopic partial nephrectomy can be safely performed for multiple ipsilateral tumors with perioperative outcomes similar to those in patients with a solitary tumor.

Robotic intracorporeal orthotopic ileal neobladder: replicating open surgical principles.

BACKGROUND: Robotic radical cystectomy (RC) for cancer is beginning to gain wider acceptance. Yet, the concomitant urinary diversion is typically performed extracorporeally at most centers, primarily because intracorporeal diversion is perceived as technically complex and arduous. Previous reports on robotic, intracorporeal, orthotopic neobladder may not have fully replicated established open principles of reservoir configuration, leading to concerns about long-term functional outcomes. OBJECTIVE: To illustrate step-by-step our technique for robotic, intracorporeal, orthotopic, ileal neobladder, urinary diversion with strict adherence to open surgical tenets. DESIGN, SETTING, AND PARTICIPANTS: From July 2010 to May 2012, 24 patients underwent robotic intracorporeal neobladder at a single tertiary cancer center. This report presents data on patients with a minimum of 3-mo follow-up (n=8). SURGICAL PROCEDURE: We performed robotic RC, extended lymphadenectomy to the inferior mesenteric artery, and complete intracorporeal diversion. Our surgical technique is demonstrated in the accompanying video. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Baseline demographics, pathology data, 90-d complications, and functional outcomes were assessed and compared with patients undergoing intracorporeal ileal conduit diversion (n=7). RESULTS AND LIMITATIONS: Robotic intracorporeal urinary diversion was successfully performed in 15 patients (neobladder: 8 patients, ileal conduit: 7 patients) with a minimum 90-d follow-up. Median age and body mass index were 68 yr and 27 kg/m2, respectively. In the neobladder cohort, median estimated blood loss was 225 ml (range: 100-700 ml), median time to regular diet was 5 d (range: 4-10 d), median hospital stay was 8 d (range: 5-27 d), and 30- and 90-d complications were Clavien grade 1-2 (n=5 and 0), Clavien grade 3-5 (n=2 and 1), respectively. This study is limited by small sample size and short follow-up period. CONCLUSIONS: An intracorporeal technique of robot-assisted orthotopic neobladder and ileal conduit is presented, wherein established open principles are diligently preserved. This step-wise approach is demonstrated to help shorten the learning curve of other surgeons contemplating robotic intracorporeal urinary diversion.

Robotic transrectal ultrasonography during robot-assisted radical prostatectomy.

We evaluate the use of robotically manipulated transrectal ultrasound (TRUS) for real-time monitoring of prostate and periprostatic anatomy during robot-assisted prostatectomy (RAP). Ten patients with clinically organ-confined prostate cancer undergoing RAP underwent preoperative and real-time intraoperative biplanar TRUS evaluation using a robotically manipulated TRUS device (ViKY System; EndoControl Medical, Grenoble, France). Median patient age was 66 yr (range: 54-88), baseline prostate-specific antigen (PSA) was 5.3 (range: 1.3-17.9), and four patients (40%) had clinical high-grade and high-stage disease. Bilateral or unilateral nerve sparing was performed in nine patients (90%). Median time for ViKY System setup to insertion of the TRUS probe was 7 min (range: 4-12). Complete robotic TRUS evaluation was successful in all patients. Five patients (50%) had TRUS-visible hypoechoic lesions, confirmed cancerous on preoperative biopsy. Relevant intraoperative TRUS findings were relayed in real time to the robotic surgeon, particularly during dissection of the bladder neck and prostatic apex, during neurovascular bundle preservation, and when hypoechoic prostate lesions approximated nerve-preserving dissection. Negative margins were achieved in nine patients (90%), including cases where significant intraprostatic lesions abutted or extended through the prostate capsule. No complications occurred. We concluded that real-time robotic TRUS guidance during RAP is feasible and safe. Robotic TRUS can provide the console surgeon with valuable anatomic information, thus maximizing functional preservation and oncologic success.

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy.

BACKGROUND: Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped. OBJECTIVE: Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n=22) or without anatomic VMD (group 2; n=22) performed by a single surgeon from April 2010 to January 2011. INTERVENTION: Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary. MEASUREMENTS: Baseline, perioperative, and postoperative data were collected prospectively. RESULTS AND LIMITATIONS: Group 1 tumors were larger (4.3 vs 2.6 cm; p=0.011), were more often hilar (41% vs 9%; p=0.09), were medial (59% and 23%; p=0.017), were closer to the hilum (1.46 vs 3.26 cm; p=0.0002), and had a lower C index score (2.1 vs 3.9; p=0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p=0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1h), median blood loss (200 and 100ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3mg/dl). The study was limited by the relatively small sample size. CONCLUSIONS: Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.

Robotic and laparoscopic high extended pelvic lymph node dissection during radical cystectomy: technique and outcomes.

BACKGROUND: With the increasing use of laparoscopic and robotic radical cystectomy (RC), there are perceived concerns about the adequacy of lymph node dissection (LND). OBJECTIVE: Describe the robotic and laparoscopic technique and the short-term outcomes of high extended pelvic LND (PLND) up to the inferior mesenteric artery (IMA) during RC. DESIGN, SETTING, AND PARTICIPANTS: From January 2007 through September 2009, we performed high extended PLND with proximal extent up to the IMA (n=10) or aortic bifurcation (n=5) in 15 patients undergoing robotic RC (n=4) or laparoscopic RC (n=11) at two institutions. SURGICAL PROCEDURE: We performed robotic extended PLND with the proximal extent up to the IMA or aortic bifurcation. The LND was performed starting from the right external iliac, obturator, internal iliac, common iliac, preaortic and para-aortic, precaval, and presacral and then proceeding to the left side. The accompanying video highlights our detailed technique. MEASUREMENTS: Median age was 69 yr, body mass index was 26, and American Society of Anesthesiologists class ≥ 3 was present in 40% of patients. All urinary diversions, including orthotopic neobladder (n=5) and ileal conduit (n=10), were performed extracorporeally. RESULTS AND LIMITATIONS: All 15 procedures were technically successful without need for conversion to open surgery. Median operative time was 6.7h, estimated blood loss was 500 ml, and three patients (21%) required blood transfusion. Median nodal yield in the entire cohort was 31 (range: 15-78). The IMA group had more nodes retrieved (median: 42.5) compared with the aortic bifurcation group (median: 20.5). Histopathology confirmed nodal metastases in four patients (27%), including three patients in the IMA group and one patient in the aortic bifurcation group. Perioperative complications were recorded in six cases (40%). During a median follow-up of 13 mo, no patient developed local or systemic recurrence. Limitations of the study include its retrospective design and small cohort of patients. CONCLUSIONS: High extended PLND during laparoscopic or robotic RC is technically feasible. Longer survival data in a larger cohort of patients are necessary to determine the proper place for robotic and laparoscopic surgery in patients undergoing RC for high-risk bladder cancer.

Laparoscopic partial nephrectomy: a decade of evolution.

The detection of renal tumors is increasing with the widespread use of ultrasonography and CT. Laparoscopic partial nephrectomy (LPN) offers less pain, smaller scars, and shorter convalescence. Expanded indications of LPN include larger and more complex tumors, including those in hilar or central locations, multiple tumors, solitary kidneys, and patients with previous renal surgery. This procedure is in constant evolution. We describe the technical nuances of LPN over the past decade of evolution.