Robot-assisted simple prostatectomy (RASP): does it make sense?

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? The open simple prostatectomy (OSP) is the 'gold standard' for high-volume prostate adenomas. It shows very good functional results despite its invasiveness. Minimally invasive approaches, e.g. laparoscopy or holmium laser enucleation of the prostate, have been 'tested' but none have proved a substitute for the OSP. The robot-assisted approach provides optimal functional results and is easy to perform for experienced robotic surgeons. Extending the indication of robotics to low-incidence pathologies can take advantage of the opportunity to 'see the procedure' using available information technology, e.g. Youtube™ that presents as an unexpectedly useful tool. OBJECTIVE: • To evaluate the outcome, feasibility and reproducibility of a robot-assisted (RA) approach for simple prostatectomy (SP) in cases of high-volume symptomatic benign prostatic hyperplasia (HVS-BPH). PATIENTS AND METHODS: • In all, 35 consecutive patients underwent RASP for HVS-BPH using a previously described technique. • The mean prostate volume on preoperative transrectal ultrasonography was 106.6 mL. • All but two patients (with bladder calculi) had an adenoma volume of >65 mL and 27 (77.1%) >80 mL. Nine patients (25.7%) had an indwelling catheter. • The mean International Prostate Symptom Score (IPSS) was 28. RESULTS: • The median operative duration was 180 min and the mean hospital stay was 3.17 days. • The mean catheter duration was 7.4 days and discontinuous or continuous catheter irrigation was required in two and seven patients, respectively (25.1%). • In all, 10 patients (28.6%) had practically no blood loss. No patients had a transfusion. • The mean postoperative peak urinary flow was 18.9 mL/s (P < 0.001), while the mean IPSS was 7 (P < 0.001). • For costs, while superficially RASP appeared more expensive than open SP (OSP), when considering the higher costs of hospitalisation for OSP, RASP was cheaper. Also, bipolar-TURP costs in patients with large-volume prostates had rather similar costs to RASP. CONCLUSIONS: • RASP is a feasible and reproducible procedure with outcome advantages when compared with the open or with other minimally invasive techniques (laser or laparoscopy). As a result, a RA approach is worth considering in cases of high-volume prostate adenomas. • Extending the indication of the RA approach, to the SP, requires firstly that the surgeon be proficient in RA surgery and secondly that as the incidence rate of HVS-BPH is low, the surgeon has had the opportunity to 'see the procedure'.

Renal cell carcinoma and synchronous thyroid metastasis with neoplastic thrombosis of the internal jugular vein: report of a case.

A case of thyroid metastasis of a renal clear cell carcinoma is presented. The fine-needle aspiration cytology pointed out the primary tumor origin. The patient underwent robot-assisted radical nephrectomy and contextual thyroidectomy. During the operative procedure, a neoplastic thrombus extending from the thyroid metastasis and protruding into the internal jugular vein was found. As a result, thrombectomy and ligation of the internal jugular vein were required. In cases of single synchronous thyroid metastases form RCC, radical surgery should be advisable. Robotic approach allows to associate major surgery procedures, as nephrectomy, with radical metastasectomy.

Robotic vs open prostatectomy in a laparoscopically naive centre: a matched-pair analysis.

OBJECTIVE: To compare the early oncological, perioperative and functional outcomes of robotic-assisted radical prostatectomy (RARP) vs open retropubic RP (RRP) in a laparoscopically naive centre, as robotic assistance aids the laparoscopically naive surgeon in minimally invasive prostate surgery, by offering magnification and superior dexterity. PATIENTS AND METHODS: From 1 November 2006 to 31 December 2007, 120 patients had RARP; this group was followed prospectively and evaluated for early oncological, perioperative and functional outcomes (measured at 3, 6 and 12 months after surgery), and compared to a historical control group of consecutive patients who had RRP from 20 May 2004 to 28 February 2007. All patients were operated by the same laparoscopically naive surgeons. The comparison was by matched-pair analysis. RESULTS: The baseline characteristics of the two groups were equivalent, although there was a higher percentage of patients with pT3/pT4 disease in the RRP group. As a proxy for oncological outcome, positive surgical margins were equivalent in the two groups (22% RARP vs 25% RRP, P = 0.77). The overall mean (range) surgical duration was significantly longer in RARP group, at 215 (165-450) min vs 160 (90-240) min in the RRP group (P < 0.001). However, RARP had a statistically significant advantage over RRP for estimated blood loss, of 200 vs 800 mL (P < 0.001), duration of catheterization (6 vs 7 days P < 0.001) and length of stay (3 vs 6 days, P < 0.001) The 3, 6 and 12-month continence rates were 70%, 93% and 97% vs 63%, 83% and 88% after RARP and RRP, respectively (P = 0.15, 0.011 and 0.014). The 3, 6 and 12 month overall potency recovery rate was 31%, 43% and 61% vs 18%, 31% and 41%, after RARP and RRP, respectively (P = 0.006, 0.045 and 0.003). CONCLUSION: Our initial experience showed the feasibility of RARP in a laparoscopically naive centre. RRP seems to be a faster procedure, whereas RARP provided better results in terms of estimated blood loss, hospitalization and functional results. The early oncological outcome seemed to be equivalent in the two groups.

Bilateral ureteroarterial fistula: a case report and review of literature.

Ureteral arterial fistula (UAF) is an uncommon condition characterized by a direct fistulous communication between a ureter and an iliac artery resulting in bleeding into the ureter, which can be massive and life-threatening because of hemodynamic instability, as confirmed by the high mortality rate (7-23% overall).This condition is actually increasing in frequency because of its relation to predisposing factors such as vascular pathology, previous radiation therapy, previous surgery, and necessity of ureteral stenting. Diagnosis is often challenging, as in most patients, the only symptom is hematuria and the treatment may require a multidisciplinary approach, including the expertise of the urologist, vascular surgeon, and interventional radiologist. Endovascular approach offers advantages over open surgery decreasing morbidity (reduced risk of injury to adjacent structure) and shortening hospital staying. There is no consensus regarding the safety of intentional occlusion of the hypogastric artery: proximal occlusion of a hypogastric artery typically produces little or no clinical symptoms due to well-collateralized pelvic arterial networks. On the contrary, significant complications, such as colonic ischemia, spinal cord paralysis, buttock claudication, or erectile dysfunction, are well-recognized adverse events after hypogastric artery embolization, especially in bilateral cases. We describe our experience of a bilateral UAF treated with bilateral endvascular approach.

Intracavitary immunotherapy and chemotherapy for upper urinary tract cancer: current evidence.

A review of the literature was performed to summarize current evidence regarding the efficacy of topical immunotherapy and chemotherapy for upper urinary tract urothelial cell carcinoma (UUT-UCC) in terms of post-treatment recurrence rates. A Medline database literature search was performed in March 2012 using the terms upper urinary tract, urothelial cancer, bacillus Calmette-Guérin (BCG), and mitomycin C. A total of 22 full-text articles were assessed for eligibility, and 19 studies reporting the outcomes of patients who underwent immunotherapy or chemotherapy with curative or adjuvant intent for UUT-UCC were chosen for quantitative analysis. Overall, the role of immunotherapy and chemotherapy for UUT-UCC is not firmly established. The most established practice is the treatment of carcinoma in situ (CIS) with BCG, even if a significant advantage has not yet been proven. The use of BCG as adjuvant therapy after complete resection of papillary UUT-UCC has been studied less extensively, even if recurrence rates are not significantly different than after the treatment of CIS. Only a few reports describe the use of mitomycin C, making it difficult to obtain significant evidence.

Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a critical review of outcomes reported by high-volume centers.

PURPOSE: To critically review perioperative outcomes, positive surgical margin (PSM) rates, and functional outcomes of several large series of retropubic radical prostatectomy (RRP), laparoscopic RP (LRP), and robot-assisted radical prostatectomy (RARP) currently available in the literature. METHODS: A Medline database search was performed from November 1994 to May 2009, using medical subject heading search terms "prostatectomy" and "Outcome Assessment (Health Care)" and text words "retropubic," "robotic," and "laparoscopic." Only studies with a sample size of 250 or more patients were considered. Weighted means were calculated for all outcomes using the number of patients included in each study as the weighing factor. RESULTS: We identified 30 articles for RRP, 14 for LRP, and 14 for RARP. The mean intraoperative and postoperative RRP transfusion rates for RRP, LRP, and RARP were 20.1%, 3.5%, and 1.4%, respectively. The weighted mean postoperative complication rates for RRP, LRP, and RARP were 10.3% (4.8% to 26.9%), 10.98% (8.9 to 27.7%), and 10.3% (4.3% to 15.7%), respectively. RARP revealed a mean overall PSM rate of 13.6%, whereas LRP and RRP yielded a PSM of 21.3% and 24%, respectively. The weighted mean continence rates at 12 month follow-up for RRP, LRP, and RARP were 79%, 84.8%, and 92%, respectively. The weighted mean potency rates for patients who underwent unilateral or bilateral nerve sparing, at 12 month follow-up, were 43.1% and 60.6% for RRP, 31.1% and 54% for LRP, and 59.9% and 93.5% for RARP. CONCLUSION: RRP, LRP, and RARP performed in high-volume centers are safe options for treatment of patients with localized prostate cancer, presenting similar overall complication rates. LRP and RARP, however, are associated with decreased operative blood loss and decreased risk of transfusion when compared with RRP. Our analysis including high-volume centers also showed lower weighted mean PSM rates and higher continence and potency rates after RARP compared with RRP and LRP. However, the lack of randomized trials precludes definitive conclusions.