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.

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.

Zero ischemia anatomical partial nephrectomy: a novel approach.

PURPOSE: We present a novel concept of zero ischemia anatomical robotic and laparoscopic partial nephrectomy. MATERIALS AND METHODS: Our technique primarily involves anatomical vascular microdissection and preemptive control of tumor specific, tertiary or higher order renal arterial branch(es) using neurosurgical aneurysm micro-bulldog clamps. In 58 consecutive patients the majority (70%) had anatomically complex tumors including central (67%), hilar (26%), completely intrarenal (23%), pT1b (18%) and solitary kidney (7%). Data were prospectively collected and analyzed from an institutional review board approved database. RESULTS: Of 58 cases undergoing zero ischemia robotic (15) or laparoscopic (43) partial nephrectomy, 57 (98%) were completed without hilar clamping. Mean tumor size was 3.2 cm, mean ± SD R.E.N.A.L. score 7.0 ± 1.9, C-index 2.9 ± 2.4, operative time 4.4 hours, blood loss 206 cc and hospital stay 3.9 days. There were no intraoperative complications. Postoperative complications (22.8%) were low grade (Clavien grade 1 to 2) in 19.3% and high grade (Clavien grade 3 to 5) in 3.5%. All patients had negative cancer surgical margins (100%). Mean absolute and percent change in preoperative vs 4-month postoperative serum creatinine (0.2 mg/dl, 18%), estimated glomerular filtration rate (-11.4 ml/minute/1.73 m(2), 13%), and ipsilateral kidney function on radionuclide scanning at 6 months (-10%) correlated with mean percent kidney excised intraoperatively (18%). Although 21% of patients received a perioperative blood transfusion, no patient had acute or delayed renal hemorrhage, or lost a kidney. CONCLUSIONS: The concept of zero ischemia robotic and laparoscopic partial nephrectomy is presented. This anatomical vascular microdissection of the artery first and then tumor allows even complex tumors to be excised without hilar clamping. Global surgical renal ischemia is unnecessary for the majority of patients undergoing robotic and laparoscopic partial nephrectomy at our institution.

Primary Whole-gland Cryoablation for Prostate Cancer: Biochemical Failure and Clinical Recurrence at 5.6 Years of Follow-up.

We retrospectively evaluated complications and functional and oncologic outcomes of 94 consecutive men who underwent primary whole-gland cryoablation for localized prostate cancer (PCa) from 2002 to 2012. Kaplan-Meier and multivariable Cox regression analyses were performed using a landmark starting at 6 mo of follow-up. In total, 75% patients had D'Amico intermediate- (48%) or high- (27%) risk PCa. Median follow-up was 5.6 yr. Median time to prostate-specific antigen (PSA) nadir was 3.3 mo, and 70 patients reached PSA <0.2ng/ml postcryoablation. The 90-d high-grade (Clavien Grade IIIa) complication rate was 3%, with no rectal fistulas reported. Continence and potency rates were 96% and 11%, respectively. The 5-yr biochemical failure-free survival (PSA nadir+2ng/ml) was 81% overall and 89% for low-, 78% for intermediate-, and 80% for high-risk PCa (p=0.46). The median follow-up was 5.6 and 5.1 yr for patients without biochemical failure and with biochemical failure, respectively. The 5-yr clinical recurrence-free survival was 83% overall and 94% for low-, 84% for intermediate-, and 69% for high-risk PCa (p=0.046). Failure to reach PSA nadir <0.2ng/ml within 6 mo postcryoablation was an independent predictor for biochemical failure (p=0.006) and clinical recurrence (p=0.03). The 5-yr metastases-free survival was 95%. Main limitation is retrospective evaluation. Primary whole-gland cryoablation for PCa provides acceptable medium-term oncologic outcomes and could be an alternative for radiation therapy or radical prostatectomy. PATIENT SUMMARY: Cryoablation is a safe, minimally-invasive procedure that uses cold temperatures delivered via probes through the skin to kill prostate cancer (PCa) cells. Whole-gland cryoablation may offer an alternative treatment option to surgery and radiotherapy. We found that patients had good cancer outcomes 5 yr after whole-gland cryoablation, and those with a prostate-specific antigen value ≥0.2ng/ml within 6 mo after treatment were more likely to have PCa recurrence.

Genomic, epidemiological and digital surveillance of Chikungunya virus in the Brazilian Amazon.

BACKGROUND: Since its first detection in the Caribbean in late 2013, chikungunya virus (CHIKV) has affected 51 countries in the Americas. The CHIKV epidemic in the Americas was caused by the CHIKV-Asian genotype. In August 2014, local transmission of the CHIKV-Asian genotype was detected in the Brazilian Amazon region. However, a distinct lineage, the CHIKV-East-Central-South-America (ECSA)-genotype, was detected nearly simultaneously in Feira de Santana, Bahia state, northeast Brazil. The genomic diversity and the dynamics of CHIKV in the Brazilian Amazon region remains poorly understood despite its importance to better understand the epidemiological spread and public health impact of CHIKV in the country. METHODOLOGY/PRINCIPAL FINDINGS: We report a large CHIKV outbreak (5,928 notified cases between August 2014 and August 2018) in Boa vista municipality, capital city of Roraima's state, located in the Brazilian Amazon region. We generated 20 novel CHIKV-ECSA genomes from the Brazilian Amazon region using MinION portable genome sequencing. Phylogenetic analyses revealed that despite an early introduction of the Asian genotype in 2015 in Roraima, the large CHIKV outbreak in 2017 in Boa Vista was caused by an ECSA-lineage most likely introduced from northeastern Brazil. Epidemiological analyses suggest a basic reproductive number of R0 of 1.66, which translates in an estimated 39 (95% CI: 36 to 45) % of Roraima's population infected with CHIKV-ECSA. Finally, we find a strong association between Google search activity and the local laboratory-confirmed CHIKV cases in Roraima. CONCLUSIONS/SIGNIFICANCE: This study highlights the potential of combining traditional surveillance with portable genome sequencing technologies and digital epidemiology to inform public health surveillance in the Amazon region. Our data reveal a large CHIKV-ECSA outbreak in Boa Vista, limited potential for future CHIKV outbreaks, and indicate a replacement of the Asian genotype by the ECSA genotype in the Amazon region.

Advances in Robotic Vena Cava Tumor Thrombectomy: Intracaval Balloon Occlusion, Patch Grafting, and Vena Cavoscopy.

Robotic level III inferior vena cava (IVC) tumor thrombectomy was described recently. We present ongoing robotic advances in this arena in a case series of six patients with Mayo level II-III thrombi who underwent robotic caval thrombectomy, radical nephrectomy, and retroperitoneal lymphadenectomy. In four patients, proximal intra- or retrohepatic IVC control was obtained solely with an intracaval Fogarty balloon catheter; in one patient, robot-guided flexible cystoscopy of the IVC lumen was performed to rule out any residual or secondary skip thrombi. In one patient, the caval wall defect after thrombus excision was reconstructed robotically using a bovine pericardial patch. Finally, a patient with concomitant renal and adrenal tumors had two distinct thrombi of levels I and III; a robotic double thrombectomy was performed. Mean renal tumor size was 8.4cm (±1.6). Four thrombi (66%) were level III. Mean operative time was 6.4h (±1.7); IVC clamp time, 53.5min (±29.8); blood loss, 668ml (±692); and hospital stay, 5.5 d (±3.8). Two patients required blood transfusions. Complications included Clavien grade 1 (n=2), grade 3a (n=1), and grade 5 (n=1). Mean follow-up was 5.8 mo (±4.3). Robotic IVC thrombectomy is a viable alternative to open surgery for appropriately selected cases by experienced teams. PATIENT SUMMARY: We present ongoing robotic surgical advances in a case series of six patients with blood clots in the inferior vena cava. These innovations will help further advance the field.

Robot-assisted bladder diverticulectomy.

PURPOSE: To describe our technique for robot-assisted bladder diverticulectomy (RABD). PATIENTS AND METHODS: Ten patients underwent RABD using an extra- or transvesical approach. Three (30%) patients underwent concomitant procedures: Robot-assisted radical prostatectomy, robot-assisted simple prostatectomy, and transurethral resection of the prostate. RESULTS: All RABDs were performed successfully. Median estimated blood loss, operative time, and diverticulectomy time were 75 mL, 210 minutes, and 80 minutes, respectively. Median follow-up time was 18 months. Median International Prostate Symptom Score decreased by 57%, P=0.001. CONCLUSIONS: RABD is feasible and safe. It can be performed via a trans- or extravesical approach, as a stand-alone, or concomitant procedure.

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.

Three-dimensional surgical navigation model with TilePro display during robot-assisted radical prostatectomy.

Abstract To facilitate robotic nerve-sparing radical prostatectomy, we developed a novel three-dimensional (3D) surgical navigation model that is displayed on the TilePro function of the da Vinci® surgeon console. Based on 3D transrectal ultrasonography (TRUS)-guided prostate biopsies, we reconstructed a 3D model of the TRUS-visible, histologically confirmed "index" cancer lesion in 10 consecutive patients. Five key anatomic structures (prostate, image-visible biopsy-proven "index" cancer lesion, neurovascular bundles, urethra, and recorded biopsy trajectories) were image-fused and displayed onto the TilePro function of the robotic console. The 3D model facilitated careful surgical dissection in the vicinity of the biopsy-proven index lesion. Geographic location of the index lesion on the final histology report correlated with the software-created 3D model. Negative surgical margins were achieved in 90%, except for one case with extensive extra-prostate extension. At postoperative 3 months, prostate-specific antigen levels were undetectable (<0.03 ng/mL) in all cases. The initial experience of the navigation model is presented.

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.

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.

Internal thoracic artery graft (ITAG): patency and functional status at rest and during dobutamine-stress echocardiography.

BACKGROUND: The patent internal thoracic artery graft (ITAG) usually has a diastolic fraction (DF) > 50% of the flow. The functional assessment can be evaluated by the coronary reserve index (CRI). OBJECTIVE: The objective was to evaluate the patency and functional status of the ITAG through echocardiography and Doppler. METHODS: Data from sixty-six patients who underwent dobutamine-stress echocardiography (DSE) were prospectively collected and analyzed. Group I (GI) had 49 ITAG without stenosis, Group II (GII), 10 ITAG with significant stenosis (> 50% and <100%) and Group III (GIII) had 7 ITAG with total occlusion. Diameters and Doppler spectrums from the ITAG at rest and during DSE were evaluated. RESULTS: Considering patency a DF >50%, it was observed in 49 ITAG (GI= 40, GII= 8 and GIII= 1) at rest and in 61 ITAG (GI=49, GII=10 and GIII=2) during DSE. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were respectively, 81%, 86%, 98%, 35% and 82%, and 100%, at rest and 71%, 97%, 100% and 97% in the DSE. The ITAG with DF>50% at rest were patent and the ones with DF<50% in the DSE presented total occlusion. Considering a CRI>1.8 for a good functional status, it was observed in 42 ITAG (39 from GI, 2 from GII and 1 from GIII), determining sensitivity=79%, specificity=85.7%, PPV=94%, NPV=59% and accuracy= 80.9%. The CRI in GI was higher (p= 0.02) than in GII or GIII. CONCLUSION: In our study, the non-invasive assessment of the ITAG was effective to verify the patency and the functional status.

Internal thoracic artery graft (ITAG): patency and functional status at rest and during dobutamine-stress echocardiography / Artéria torácica interna enxertada: patência e estado funcional em repouso e após dobutamina

FUNDAMENTO: A artéria torácica interna enxertada (ATIE) patente usualmente tem fração diastólica (FD)> 50 por cento do fluxo. O estado funcional pode ser avaliado pelo índice de reserva coronariano (IRC). OBJETIVO: Avaliar, pela ecocardiografia e pelo Doppler em nível supraclavicular, a patência e o estado funcional da ATIE. MÉTODOS: Foram coletados prospectivamente e analisados os dados de 66 pacientes submetidos a ecocardiograma sob estresse com dobutamina (EED). O grupo I (GI) ocorreu com 49 ATIE sem estenose. No grupo II (GII) (10 ATIE) havia estenose significativa (> 50 por cento e <100 por cento). E no grupo III (GIII) (7 ATIE) a oclusão era de 100 por cento. Foram avaliados diâmetros e espectros do Doppler das ATIE no repouso e EED. RESULTADOS: Considerando patência uma FD>50 por cento, ocorreu em 49 ATIE (GI=40, GII=8 e GIII=1) no repouso e em 61 ATIE (GI=49, GII=10 e GIII=2) durante EED. Sensibilidade, especificidade, valor preditivo positivo (VPP), valor preditivo negativo (VPN) e acurácia foram, respectivamente, em repouso, 81 por cento, 86 por cento ,98 por cento, 35 por cento e 82 por cento; e no EED, 100 por cento, 71 por cento, 97 por cento, 100 por cento e 97 por cento. As ATIE com FD>50 por cento em repouso estavam patentes e as com FD<50 por cento no EED tinham oclusão total. Considerando para bom estado funcional um IRC>1,8, isso ocorreu em 42 ATIE (39 do GI, 2 do GII e 1 GIII), verificando-se sensibilidade = 79 por cento; especificidade = 85,7 por cento; VPP = 94 por cento; VPN = 59 por cento; e acurácia = 80,9 por cento. O IRC no GI foi maior (p=0,02) que em GII e GIII. CONCLUSÃO: Em nosso estudo, a avaliação não-invasiva da ATIE foi efetiva para verificar patência e estado funcional.

BACKGROUND: The patent internal thoracic artery graft (ITAG) usually has a diastolic fraction (DF) > 50 percent of the flow. The functional assessment can be evaluated by the coronary reserve index (CRI). OBJECTIVE: The objective was to evaluate the patency and functional status of the ITAG through echocardiography and Doppler. METHODS: Data from sixty-six patients who underwent dobutamine-stress echocardiography (DSE) were prospectively collected and analyzed. Group I (GI) had 49 ITAG without stenosis, Group II (GII), 10 ITAG with significant stenosis (> 50 percent and <100 percent) and Group III (GIII) had 7 ITAG with total occlusion. Diameters and Doppler spectrums from the ITAG at rest and during DSE were evaluated. RESULTS: Considering patency a DF >50 percent, it was observed in 49 ITAG (GI= 40, GII= 8 and GIII= 1) at rest and in 61 ITAG (GI=49, GII=10 and GIII=2) during DSE. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were respectively, 81 percent, 86 percent, 98 percent, 35 percent and 82 percent, and 100 percent, at rest and 71 percent, 97 percent, 100 percent and 97 percent in the DSE. The ITAG with DF>50 percent at rest were patent and the ones with DF<50 percent in the DSE presented total occlusion. Considering a CRI>1.8 for a good functional status, it was observed in 42 ITAG (39 from GI, 2 from GII and 1 from GIII), determining sensitivity=79 percent, specificity=85.7 percent, PPV=94 percent, NPV=59 percent and accuracy= 80.9 percent. The CRI in GI was higher (p= 0.02) than in GII or GIII. CONCLUSION: In our study, the non-invasive assessment of the ITAG was effective to verify the patency and the functional status.