Short-term quality-of-life assessed after robot-assisted radical cystectomy: a prospective analysis.

OBJECTIVE: To prospectively determine the effect of robot-assisted radical cystectomy (RARC) on quality of life (QoL) after surgery. PATIENTS AND METHODS: In all, 34 patients who had RARC for bladder cancer between January 2006 and December 2007 at one institution were prospectively enrolled in a study of QoL. All patients had RARC with extracorporeal urinary diversion by one surgeon. As part of the routine follow-up, QoL was assessed at intervals. Functional Assessment of Cancer Therapy-Bladder (FACT-BL) questionnaires were administered before and then over a 6-month period after RARC. Patients undergoing chemotherapy were not excluded. Follow-up FACT-BL and individual domain scores for physical, social, emotional and functional well-being were compared with those obtained before RARC. RESULTS: The mean age of all patients was 65 years, 88% were men, and 13 (38%) had adjuvant chemotherapy. The mean time after RARC for the 1-, 3- and 6-month assessments was 29, 90 and 193 days, respectively; 19 patients completed three follow-up questionnaires. Initially, there were significant decreases in the physical and functional domains, with improvements in the emotional domain (P < 0.001). Total FACT-General and FACT-BL scores decreased in the initial period after RARC and then progressively improved. There was no statistically significant difference in total scores at 3 months after surgery; at the 6-month follow-up the total FACT-BL scores exceeded those before RARC (P = 0.048). CONCLUSIONS: QoL appears to return promptly to, or exceed, baseline levels by 6 months after RARC. The improvement in the short term might allow for more contented patients and quicker initiation of adjuvant chemotherapy.

Current status of robot-assisted surgery in urology: a multi-national survey of 297 urologic surgeons.

PURPOSE: The surgical robot is becoming an important tool for performance of minimally invasive surgical procedures around the world. We surveyed opinions about and utilization of robot-assisted surgery among urologic surgeons from 44 countries. MATERIAL AND METHODS: A total of 297 surveys were completed from September to November 2008 by participating urologic surgeons polled at various national and international urologic meetings. The survey evaluated surgeon background, personal experience with minimally invasive surgery, institutional status regarding robotic surgery surgeons' attitudes towards robot-assisted surgery, in general, and prostate, bladder and kidney oncologic procedures, specifically. RESULTS: Two hundred ninety-seven participants completed the survey of which 35% were in training for and 54% in practice of urology. Although 57% of these participants were older than 40, 62% had never sat on a robotic surgical console but 61% believed they would perform robot-assisted surgery. Seventy-eight percent of respondents felt it was required or beneficial to have training in robot-assisted surgery. Only 21% of respondents were currently performing robot-assisted radical prostatectomy. Sixty-one percent of respondents felt robot-assisted radical prostatectomy was the current gold standard or as good as laparoscopic prostatectomy. Only 10% had performed robot-assisted radical cystectomy and 70% of these surgeons have transferred skills from robot-assisted radical prostectomy. Ten percent were performing robot-assisted radical nephrectomies and 30% had transferred skills for laparoscopic partial nephrectomy to robot-assisted partial nephrectomy. CONCLUSION: Robot-assisted surgery has begun to integrate into the minimally invasive armamentarium for urologic surgery and is applied for more procedures as experience is gained.

The learning curve for robot-assisted radical cystectomy.

OBJECTIVE: Robot-assisted radical cystectomy has the potential to cure patients from bladder cancer while offering the benefits of minimally invasive surgery. We sought to evaluate the learning curve for this technically demanding procedure. MATERIALS AND METHODS: Robot-assisted radical cystectomy was attempted in 100 consecutive patients. An IRB-approved review of our robot-assisted radical cystectomy database was conducted. Total operative (OR) time, cystectomy time, pelvic lymph node dissection (PLND) time, estimated blood loss (EBL), margin positivity, complications, and length of hospital stay were compared among patients divided into 4 cohorts of increasing surgical experience. Scattergrams and continuous curves were plotted to develop a robotic cystectomy learning curve. RESULTS: Overall OR time decreased from 375 minutes in cohort 1 to 352 minutes in cohort 4, with less than 1% change in OR time after case 16. Time from incision to bladder extirpation decreased from 187 minutes in cohort one to 165 minutes in cohort 4. Time for PLND increased from 44 minutes in cohort 1 to 77 minutes in cohort 4. Lymph node yield increased from 14 nodes in cohort 1 to 23 nodes in cohort 4. Positive surgical margins decreased from 4 patients in cohort 1 to 0 patient in cohort 4. The complication rate had no change from 9 patients in cohort 1 to 9 patients in cohort 4. CONCLUSION: Operative results and oncologic outcomes for robot-assisted radical cystectomy constantly improve as the technique evolves.

Impact of body mass index on robot-assisted radical cystectomy.

BACKGROUND AND OBJECTIVES: Obesity is a major comorbidity in the Western world and influences outcomes of patient care. A minimally invasive approach towards radical cystectomy has been increasing in popularity. We sought to determine the influence of body mass index (BMI) on robot-assisted radical cystectomy. METHODS: Fifty-one consecutive patients underwent robot-assisted radical cystectomy for bladder cancer from October 2005 to April 2007 and were categorized into 3 groups based on their weight: normal (BMI <25), overweight (BMI=25 to 29) and obese (BMI= 30 to 39.9). Effect of BMI on intraoperative, pathologic, and postoperative outcomes was assessed by retrospective review of the robot-assisted radical cystectomy database. RESULTS: Mean BMI was 28.0, and 71% of the patients were overweight or obese. BMI did not correlate with age, sex, or American Society of Anesthesiologists (ASA) score. Overweight and obese patients had similar operative times and estimated blood loss compared with patients with normal BMI. Overweight and obese patients with bulky disease (pT3-4) had significantly higher rates of positive surgical margins (P=0.05). Complication rates were similar. CONCLUSION: Robotic-assisted radical cystectomy can be considered for patients of all body mass indices. Wider excision should be performed in patients with higher BMI.

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.

Robot-assisted radical cystectomy versus open radical cystectomy: assessment of postoperative pain.

INTRODUCTION: To date, no study has compared postoperative pain and requirement for pain medications in open versus robot-assisted radical cystectomy. Patient reported pain and opiate use were reviewed retrospectively using prospectively collected data from postoperative day one to day of discharge. MATERIALS AND METHODS: Twenty consecutive robot-assisted radical cystectomy patients were compared to the prior 20 patients who underwent open radical cystectomy. Data was collected prospectively to determine opiate requirements and pain scores in each group. Daily opiate use was converted to morphine sulfate equivalents (MSE) to facilitate comparison. A Likert pain perception scale was used to assess perceived pain. Statistical models were used to test for differences in opiate usage and pain perception between groups of patients who underwent open versus robot-assisted surgery. RESULTS: Seven patients were excluded from the study (three from the open group, and four from the robotic group): five due to preoperative opiate usage, one due to missing pain data, and one whose procedure was aborted due to unresectable disease. All patients were similar with respect to age, body mass index and pathological parameters. Average MSE usage differed significantly between the two groups on all postoperative days (p < 0.007) whereas average pain scores were similar in the two groups. CONCLUSION: Patients who underwent robot-assisted radical cystectomy achieved similar pain control but required less opiates than those who underwent open radical cystectomy.

Comparative analysis of global practice patterns in urologic robot-assisted surgery.

OBJECTIVES: To determine and compare the status of urologic laparoscopic and robot-assisted surgery (RAS) across the world. METHODS: Two hundred ninety-one surveys were completed by urologists at various national and international conferences in 2008. The 58-item questionnaire assessed the individual and institutional practice patterns of minimally invasive surgery with a focus on RAS. Surveys from Europe and North American continents (ENA) were compared with surveys from the Middle East and Asian continents (MEA). RESULTS: One hundred sixty-six (57%) surveys were completed by urologists from MEA and 125 (43%) from ENA. Eighty percent of respondents performed minimally invasive surgery, with 64% having prior formal training. Respondents in ENA were more likely to have had formal training in RAS and performed more RAS cases (p < 0.01). Sixty percent of those surveyed from ENA had used robotic consoles in training courses compared with only 20% in MEA (p < 0.01). Dedicated RAS support teams were less common in MEA (p < 0.01). Lack of a robotic system was the most common deterrent for RAS in MEA (56%). Respondents in ENA performed more robot-assisted radical prostatectomy, robot-assisted radical cystectomy, and robot-assisted nephrectomy. In the more established robotic environment of ENA, robot-assisted radical prostatectomy, robot-assisted radical cystectomy, and robot-assisted nephrectomy represented the gold standard in 34%, 14%, and 26% of surveys, respectively. Comparatively, MEA respondents were more likely to believe RAS represented the gold standard. CONCLUSIONS: Usage of RAS in urology continues to grow across the globe, though to most it represents a surgical alternative rather than benchmark. Even with reduced exposure, training, and access, more urologists in the MEA considered RAS to be the surgical standard for prostatectomy, cystectomy, and nephrectomy. The evolution of attitudinal change should be the focus of further study.

Robot-assisted radical cystectomy and pelvic lymph node dissection: initial experience at Roswell Park Cancer Institute.

OBJECTIVES: One series of robot-assisted radical cystectomy with pelvic lymph node dissection has been reported. We report our operative technique and initial experience. METHODS: Twenty consecutive patients underwent robot-assisted radical cystectomy, pelvic lymph node dissection, and open urinary diversion for operable bladder cancer from October 2005 to June 2006. Data were collected prospectively on patient demographics, intraoperative parameters, pathologic staging, and postoperative outcomes. RESULTS: The mean patient age was 70 years (range 56 to 90). The mean body mass index was 26 kg/m2 (range 17.3 to 36). Fourteen patients had undergone previous abdominal surgery. The mean operative time was 197 minutes for robot-assisted radical cystectomy, 44 minutes for pelvic lymph node dissection, and 133 minutes for urinary diversion. The mean blood loss was 555 mL. One case was converted to an open procedure because of the patient's inability to tolerate the Trendelenburg position. The mean hospital stay was 10 days. Two patients had major complications. One patient had positive vaginal margins and 9 of 26 nodes were positive. Four patients had incidental prostate cancer. The mean time to the return to nonstrenuous activity was 4 weeks and to strenuous activity was 10 weeks. CONCLUSIONS: Robot-assisted radical cystectomy and pelvic lymph node dissection can be performed safely in patients who are considered candidates for open cystectomy. Long-term oncologic control data and functional outcomes are needed to assess the true benefits of robot-assisted radical cystectomy.