Cystolithotomy during robotic radical prostatectomy: Single-stage procedure for concomitant bladder stones.

Asymptomatic concomitant vesical calculi are an occasional finding on routine radiologic staging and evaluation of patients with early prostate cancer. We report the first case of single-stage robotic cystolithotomy for multiple bladder stones in a 64-year-old man undergoing robotic-assisted radical prostatectomy, and discuss the approaches available for ensuring complete stone clearance in this unique setting. We show that concomitant bladder stone extraction during robotic-assisted radical prostatectomy is feasible and does not add significantly to operative time. This technique avoids the need to undergo additional general anesthetic procedures with potential complications such as bleeding, urethral stricture formation, and bladder perforation, prior to the prostatectomy.

Clinical and pathologic predictors of Gleason sum upgrading in patients after radical prostatectomy: results from a single institution series.

OBJECTIVES: Preoperative Gleason scores (GSs) are often upgraded after pathologic examination of the prostate following radical prostatectomy (RP). There have been disparate reports of the impact of different factors as predictors of GS upgrading after RP. We sought to study the robustness of frequently reported predictors in an unselected single institution cohort. PATIENTS AND METHODS: A total of 684 patients with biopsy-proven prostate cancer treated with RP between 2004 and 2007 were included in the study. The association between clinical and pathologic parameters and GS upgrading was retrospectively evaluated. Logistic regression analysis was used to identify predictors of pathologic grading changes. Likelihood of upgrading was compared between tertile groups for prostate volume and prostate-specific antigen (PSA) density using χ(2) analysis and multivariate logistic regression. Pathologic outcomes were compared between cases with and without GS upgrading. RESULTS: The overall mean age was 64.3 years, with median PSA level of 7.04 ng/ml. Overall, 203 cases (29.7%) were upgraded, whereas 481 patients (70.3%) were downgraded or had identical biopsy and pathologic GS after RP. Patients with prostate volume of <31 g were upgraded in 32.6% of the cases compared with 21.9% in patients with prostate volume of >45 g (P = 0.020). On multivariate analysis preoperative PSA (P < 0.0001), prostate volume (P < 0.0001), and PSA density (P < 0.0001) were predictive of Gleason sum upgrading. Upgraded patients were more likely to have extracapsular extension, seminal vesicle invasion, positive surgical margins, and lymphonodular invasion at RP (P < 0.001, P < 0.001, P < 0.001, and P < 0.001, respectively). CONCLUSIONS: Smaller prostate volume and higher PSA level are associated with clinically significant upgrading of GS. PSA density as a function of both is a significant predictor of GS upgrading in low- and high-risk patients. This may be of relevance in the pretreatment risk assessment of prostate cancer patients.

Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection: a novel approach for ameliorating apical margin positivity during robotic radical prostatectomy.

OBJECTIVE: To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. PATIENTS AND METHODS: Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. RESULTS: Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P = 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥ pT3a) documented on final specimen pathology (16% vs 10%, P = 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. CONCLUSION: Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.

Residency training program paradigms for teaching robotic surgical skills to urology residents.

The advent of laparoscopic and robotic techniques for management of urologic malignancies marked the beginning of an ever-expanding array of minimally invasive options available to cancer patients. With the popularity of these treatment modalities, there is a growing need for trained surgical oncologists who not only have a deep understanding of the disease process and adept surgical skills, but also show technical mastery in operating the equipment used to perform these techniques. Establishing a robotic prostatectomy program is a tremendous undertaking for any institution, as it involves a huge cost, especially in the purchasing and maintenance of the robot. Residency programs often face many challenges when trying to establish a balance between costs associated with robotic surgery and training of the urology residents, while maintaining an acceptable operative time. Herein we describe residency training program paradigms for teaching robotic surgical skills to urology residents. Our proposed paradigm outlines the approach to compensate for the cost involved in robotic training establishment without compromising the quality of education provided. With the potential advantages for both patients and surgeons, we contemplate that robotic-assisted surgery may become an integral component of residency training programs in the future.

Double-pigtail stenting of the ureters: technique for securing the ureteral orifices during robot-assisted radical prostatectomy for large median lobes.

Patients with large median prostate lobes undergoing robot-assisted radical prostatectomy are at potential risk of ureteric orifice injury, during posterior bladder neck transection and vesicourethral anastomosis reconstruction. We describe our technique of in situ robot-assisted ureteral stenting with double-pigtail stents for accurate observation and preservation of the ureteral orifices. We have performed this maneuver in over 30 patients in our cohort of over 1500 patients undergoing robot-assisted radical prostatectomy to date--none of these patients developed urinary leak or bladder neck contracture, and had uneventful cystoscopic removal of stents at 6 weeks after surgery.

Scientific and technical advances in continence recovery following radical prostatectomy.

The advent of prostate-specific antigen screening has changed the global epidemiology of prostate cancer, with men being diagnosed with organ-confined cancer at a younger age. Radical prostatectomy with curative intent for these patients, while delivering excellent long-term survival outcomes, still has significant side effects, chiefly postprostatectomy incontinence. Increasing age, shorter pre- and post-operative membranous urethral length, anastomotic strictures, obesity, low surgeon volume, variations of surgical technique and previous prostate surgery have been reported as negative risk factors for delayed continence recovery and/or permanent incontinence following radical prostatectomy. Significant progress in elucidating the functional anatomy and physiology of the male continence mechanism from cadaveric and videourodynamic studies have enabled surgeons to propose innovative surgical techniques during radical prostatectomy for augmenting continence preservation and early return. These have included optimizing the preservation of urethral rhabdosphincter length; avoiding rhabdosphincter injury; posterior reconstruction of Denonvilliers' musculofascial plate; preservation of the bladder neck and internal sphincter; bladder neck intussusception; bladder neck mucosal eversion; preservation of the puboprostatic ligaments and arcus tendineus; and preservation of putative nerves supplying the continence mechanism. We review the scientific and technical advances in continence recovery following radical prostatectomy, identify the key principles undergirding early return of continence, highlight various treatment strategies for early and refractory postprostatectomy incontinence and describe our experience with a paradigm of these unified key principles. Increasing application of these principles in computer-aided (robotic), minimally invasive and minimal-access (i.e., single-port or natural orifice transluminal) approaches will hopefully enable patients to derive maximal benefit from curative prostatectomy while experiencing early return of continence in the not too distant future.

Technological advances in robotic-assisted laparoscopic surgery.

In this article, the authors describe the evolution of urologic robotic systems and the current state-of-the-art features and existing limitations of the da Vinci S HD System (Intuitive Surgical, Inc.). They then review promising innovations in scaling down the footprint of robotic platforms, the early experience with mobile miniaturized in vivo robots, advances in endoscopic navigation systems using augmented reality technologies and tracking devices, the emergence of technologies for robotic natural orifice transluminal endoscopic surgery and single-port surgery, advances in flexible robotics and haptics, the development of new virtual reality simulator training platforms compatible with the existing da Vinci system, and recent experiences with remote robotic surgery and telestration.

Robot-assisted laparoscopic radical prostatectomy in the renal allograft transplant recipient.

BACKGROUND AND PURPOSE: Since the advent of immunosuppressive therapy, patients have been able to lead longer lives as transplant recipients. We report the first case of robot-assisted laparoscopic prostatectomy in the renal allograft recipient. PATIENTS AND METHODS: A 54-year-old man presented with Gleason 3+3 localized prostate cancer with a prostatespecific antigen level of 8.5 ng/mL. He had a history of end-stage renal failure secondary to fulminant acute pyelonephritis necessitating bilateral nephrectomy. Renal allograft transplant in the right iliac fossa was performed in 1981, with adequate renal function while continuing his immunosuppressant regime. The patient also had previous left inguinal herniorrhaphy. Modifications to our surgical approach include placement of a bariatric port superiolaterally to the standard port site; siting the left port inferiolaterally to provide adequate access for pelvic lymph node dissection; and developing the retropubic space largely from the contralateral side to avoid allograft injury. Extensive adhesiolysis was also needed. After negative urethral margin reported on frozen section, vesicourethral anastomosis was fashioned using our Cornell bladder neck anatomic reconstruction technique. RESULTS: The patient needed a postoperative transfusion of 1 unit of blood and was discharged on postoperative day 2 after recommencement of immunosuppression. The final pathology report revealed pT(2c) Gleason 7 (3+4) disease and negative surgical margins. Continence was recovered within the first week of catheter removal, and erections sufficient for penetration occurred before 6-week follow-up in the clinic. CONCLUSION: Robot-assisted radical prostatectomy is feasible in the carefully selected renal allograft recipient with favorable oncologic, continence, and potency outcomes.

Giant mixed-type perinephric liposarcoma.

Retroperitoneal fatty tumours are uncommon occurrences in current urologic practice, the differentials being lipomas, liposarcomas and extra-renal angiomyolipomas (AML). We report an unusual case of a 48-year-old Chinese female who presented with a 6.2 kg giant mixed-type liposarcoma in the left perinephric space, invading into the renal cortex and parenchyma. Extirpative surgery with left radical nephrectomy was performed, and histology confirmed liposarcoma with both myxoid and well-differentiated elements. The patient remains well and disease-free at 6-month follow-up. We review the literature on the diagnosis and management of these perinephric lipomatous lesions. We also discuss the diagnostic dilemma in differentiating such malignancies from benign angiomyolipomas in the perinephric area on conventional radiological imaging, and its direct implications with respect to extent of surgery and renal preservation.