Long-term biochemical recurrence rates after robot-assisted radical prostatectomy: analysis of a single-center series of patients with a minimum follow-up of 5 years.

OBJECTIVE: To address the long-term biochemical recurrence (BCR)-free survival rates of patients treated with robotic-assisted laparoscopic prostatectomy (RALP) with a minimum follow-up of 5 years. MATERIALS AND METHODS: Prospectively collected data of 184 patients treated with RALP at a single institution were analyzed. Kaplan-Meier and life tables analyses targeted the rates of BCR according to pathologic parameters. Cox regression analyses addressed predictors of BCR. RESULTS: Median follow-up was 67.5 months. One and 10 patients died of prostate cancer (PCa) and other causes, respectively. Mean time to BCR was 83.8 months. The 3-, 5-, and 7-year BCR-free survival rates were 94%, 86%, and 81%, respectively. These rates were 97%, 93%, and 85% for pT2 disease; 94%, 84%, and 84% for pT3a; and 69%, 43%, and 43% for pT3b (P<.001). The same figures were 97%, 90%, and 88% for Gleason sum 6 or lower; 90%, 86%, and 75% for Gleason sum 7; and 85%, 65%, and 65% for Gleason sum 8-10 (P=.01). At univariable analyses, prostate-specific antigen, pathologic Gleason score, and presence of extracapsular extension, seminal vesicle invasion, and adjuvant radiotherapy were significantly associated with BCR. At multivariable analysis, the presence of seminal vesicle invasion and the presence of Gleason sum 8-10 represented independent predictors of BCR (HR=5.14; P=.004 and HR=3.04; P=.04, respectively). CONCLUSION: We report the longest available follow-up in RALP patients. RALP represents an oncologically effective procedure. Our oncological results support the increasing diffusion of RALP for the treatment of organ-confined PCa.

Posterior and anterior fixation of the urethra during robotic prostatectomy improves early continence rates.

OBJECTIVE: To investigate whether posterior and anterior fixation of the vesicourethral anastomosis during robotic radical prostatectomy (RRP) helps to establish continence earlier. MATERIAL AND METHODS: Forty-seven consecutive patients undergoing RRP were randomized into two groups. The first group received a typical Van Velthoven vesicourethral anastomosis and the second group a modified anastomosis with posterior and anterior fixation. In this group the posterior fibrous tissues of the sphincter were sutured to the residual Denonvilliers' fascia. The anastomosis with two running sutures started at the 6 o'clock position on the bladder neck and continued upwards. Two-step stitching was done on the upper half of the anastomosis to ensure good stabilization of the bladder: a small portion of urethral stump followed by a deep haemostatic stitch on the plexus. Continence, as measured by patient self-reporting of the number of pads used per 24 h, was assessed 7 weeks after catheter removal, by telephone interview. The use of no pads or one pad was defined as "continent", two pads as "moderate incontinence" and more than two pads as "severe incontinence". RESULTS: At catheter removal, more patients in the fixation group were continent than in the Van Velthoven group [9/23 (39%) vs 3/24 (12.5%), p = 0.036]. At 7 weeks, continence was even better in the fixation group [15/23 (65%) vs 8/24 (33%), p = 0. 029]. The mean pad usage was less in the fixation group (1.43 vs 2.25, p = 0.032). CONCLUSIONS: The posterior and anterior fixation of the vesicourethral anastomosis during RRP results in an intact sphincteric mechanism, because no stretch is applied to the urethra, resulting in earlier continence.

Etiology of urethral stricture disease in the 21st century.

PURPOSE: We determined the current etiology of urethral stricture disease in the developed world and whether there are any differences in etiology by patient age and stricture site. MATERIAL AND METHODS: Between January 2001 and August 2007 we prospectively collected a database on 268 male patients with urethral stricture disease who underwent urethroplasty at a referral center. The database was analyzed for possible cause of stricture and for previous interventions. Subanalysis was done for stricture etiology by patient age and stricture site. RESULTS: The most important causes were idiopathy, transurethral resection, urethral catheterization, pelvic fracture and hypospadias surgery. Overall iatrogenic causes (transurethral resection, urethral catheterization, cystoscopy, prostatectomy, brachytherapy and hypospadias surgery) were the etiology in 45.5% of stricture cases. In patients younger than 45 years the main causes were idiopathy, hypospadias surgery and pelvic fracture. In patients older than 45 years the main causes were transurethral resection and idiopathy. In cases of penile urethra hypospadias surgery idiopathic stricture, urethral catheterization and lichen sclerosus were the main causes, while in the bulbar urethra idiopathic strictures were most prevalent, followed by strictures due to transurethral resection. The main cause of multifocal/panurethral anterior stricture disease was urethral catheterization, while pelvic fracture was the main cause of posterior urethral strictures. CONCLUSIONS: Of strictures treated with urethroplasty today iatrogenic causes account for about half of the urethral stricture cases in the developed world. In about 1 of 3 cases no obvious cause could be identified. The etiology is significantly different in younger vs older patients and among stricture sites.

Tumor enucleoresection in robot-assisted partial nephrectomy.

The objective of this study is to describe our technique and results of the enucleoresection technique in robot-assisted partial nephrectomy. The patient is positioned in full flank position. Three robotic arms of a da Vinci system and an assistant's port are used. The renal hilus is freed, the kidney mobilized and the site of the partial excision prepared. The vessels are clamped with a bulldog. The capsula of the kidney is incised circular about 5 mm around the tumor. A pseudocapsula of compressed healthy tissue around the tumor is found and mainly blunt dissection is done with the cold scissors. At the base of the dissection, the resection is completed sharply. Possible calyceal defects and major vessels are stitched. Fibrinogen coagulation enhancer and cellulose coagulation sponge are used to lessen the gap and the renal defect is closed with absorbable suture. The kidney is re-perfused and observed for bleeding. We have performed 17 cases with warm ischemia time 16-35 min (mean 24 min) and tumor size 2.2-5.3 cm (mean 3.8 cm). All surgical margins were tumor free. No postoperative complications were identified except one clot retention. Robot-assisted enucleoresection of kidney tumors is a feasible and very promising technique that needs to be further evaluated for results.

Failure of a robotic arm during da Vinci prostatectomy: a case report.

We report a rare case of a da Vinci robotic arm failure during a laparoscopic robot-assisted radical prostatectomy. The articulation joint of an Endowrist needle driver was broken and positioned at such an angle that made it impossible to remove through the trocar. In addition, it was later discovered that a small piece of the instrument was detached and remained inside the abdomen of the patient without even having been identified on subsequent radiological evaluation. In order to remove the broken instrument, we had to uninstall it from the robot arm and a bigger incision had to be made in the abdominal wall of the patient. The operation was completed without any other incidents. Testing the broken instrument for integrity is recommended to avoid this rare complication.