Impact of Perioperative Multidisciplinary Rehabilitation Pathway on Early Outcomes after Robot-assisted Radical Cystectomy: A Matched Analysis.

OBJECTIVE: To investigate the effect of incorporating physical rehabilitation, nutrition and psychosocial care as part of the "NEEW" (Nutrition, Exercise, patient Education and Wellness) on perioperative outcomes after robot-assisted radical cystectomy. METHODS: Patients were divided into 2 groups: pathway group (NEEW in addition to enhanced recovery after surgery), vs prepathway group, before NEEW initiation (enhanced recovery after surgery only). Propensity score matching was performed (ratio 1:2 ratio). Perioperative outcomes were analyzed and compared. Multivariate analyses were modeled to assess for association between NEEW pathway and postoperative outcomes. RESULTS: One hundred and niney-two were included in the study: 64 patients (33%) in the pathway group vs 128 patients (67%) in the prepathway group. Pathway group had shorter median inpatient stay (5 vs 6 days, P <.01), faster bowel recovery (3 vs 4 days, P <.01), and better pain scores, and demonstrated fewer 30-day high grade complications (5% vs 16%, P = .02). On multivariate analysis, the NEEW pathway was associated with shorter hospital stay (1.75 days shorter), faster bowel recovery (1 day faster), longer functional mobility time (4 minutes longer) and less pain scores (average 1 point less). CONCLUSION: Standardized perioperative pathway with weekly multidisciplinary team meeting was associated with improved short-term perioperative outcomes after robot-assisted radical cystectomy.

The CanMoRe trial - evaluating the effects of an exercise intervention after robotic-assisted radical cystectomy for urinary bladder cancer: the study protocol of a randomised controlled trial.

BACKGROUND: Patients who have undergone radical cystectomy for urinary bladder cancer are not sufficiently physically active and therefore may suffer complications leading to readmissions. A physical rehabilitation programme early postoperatively might prevent or at least alleviate these potential complications and improve physical function. The main aim of the CanMoRe trial is to evaluate the impact of a standardised and individually adapted exercise intervention in primary health care to improve physical function (primary outcome) and habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications in patients undergoing robotic-assisted radical cystectomy for urinary bladder cancer. METHODS: In total, 120 patients will be included and assigned to either intervention or control arm of the study. All patients will receive preoperative information on the importance of early mobilisation and during the hospital stay they will follow a standard protocol for enhanced mobilisation. The intervention group will be given a referral to a physiotherapist in primary health care close to their home. Within the third week after discharge, the intervention group will begin 12 weeks of biweekly exercise. The exercise programme includes aerobic and strengthening exercises. The control group will receive oral and written information about a home-based exercise programme. Physical function will serve as the primary outcome and will be measured using the Six-minute walk test. Secondary outcomes are gait speed, handgrip strength, leg strength, habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications. The measurements will be conducted at discharge (i.e. baseline), post-intervention and 1 year after surgery. To evaluate the effects of the intervention mixed or linear regression models according to the intention to treat procedure will be used. DISCUSSION: This proposed randomised controlled trial has the potential to provide new knowledge within rehabilitation after radical cystectomy for urinary bladder cancer. The programme should be easy to apply to other patient groups undergoing abdominal surgery for cancer and has the potential to change the health care chain for these patients. TRIAL REGISTRATION: ClinicalTrials.gov. Clinical trial registration number NCT03998579 . First posted June 26, 2019.

Choosing the most appropriate minimally invasive approach to treat gynecologic cancers in the context of an enhanced recovery program: Insights from a comprehensive cancer center.

OBJECTIVE: The aim of the study was to compare the characteristics of procedures for gynecologic cancers conducted with conventional laparoscopy (CL) or robotically assisted laparoscopy (RAL) in the context of an enhanced recovery program (ERP). METHODS: This is a secondary analysis of prospectively collected data from a cohort study conducted between 2016 (when the ERP was first implemented at the Institut Paoli-Calmettes, a comprehensive cancer center in France) and 2018. We included patients who had undergone minimally invasive surgery for gynecological cancers and followed our ERP. The endpoints were the analysis of postoperative complications, the length of postoperative hospitalization (LPO), and the proportion of combined procedures depending on the approach (RAL or CL). Combined procedures were defined by the association of at least two of the following operative items: hysterectomy, pelvic lymphadenectomy, and para-aortic lymphadenectomy. RESULTS: A total of 362 women underwent either CL (n = 187) or RAL (n = 175) for gynecologic cancers and followed our ERP. The proportion of combined procedures performed by RAL was significantly higher (85/175 [48.6%]) than that performed by CL (23/187 [12.3%]; p < 0.001). The proportions of postoperative complications were similar between the two groups (19.4% versus 17.1%; p = 0.59). Logistic regression analysis revealed a statistically insignificant trend in the association of RAL with a reduced likelihood of an LPO > 3 days after adjusting for predictors of prolonged hospitalization (adjusted OR = 0.573 [0.236-1.388]; p = 0.217). CONCLUSION: Experts from our cancer center preferentially choose RAL to perform gynecologic oncological procedures that present elements of complexity. More studies are needed to determine whether this strategy is efficient in managing complex procedures in the framework of an ERP.

Effects of dexmedetomidine on post-operative recovery and mental status in patients receiving robotic-assisted thoracic surgery.

BACKGROUND: This study aimed to investigate the effects of dexmedetomidine on the post-operative recovery and mental status in patients receiving robotic-assisted thoracic surgery (RATS). METHODS: One hundred patients who received selective RATS under general anesthesia were recruited and assigned into control group (C) and dexmedetomidine group (D). The anesthesia induction and maintenance were consistent between groups. Midazolam, sufentanil, propofol and rocuronium were intravenously injected for anesthesia induction, followed by mechanical ventilation after endotracheal intubation. Sevoflurane inhalation at a minimum alveolar concentration (MAC) of 0.5 was administered, propofol and remifentanil were intravenously injected to maintain the bispectral index (BIS) at 40-60, and rocuronium was intravenously injected once every 30 min. In the D group, dexmedetomidine was intravenously injected after endotracheal intubation, and then it was injected before the end of surgery. In the C group, normal saline of equal volume was injected. The hemodynamic parameters, blood loss, urine volume, time of surgery, time of anesthesia, total dose of propofol, time of thoracic tube indwelling, hospital stay and pulmonary complications were recorded; blood gas analysis was performed after extubation; the QoR-15 and mini-mental state examination (MMSE) questionnaires were employed for the assessment of mental status at 1 and 3 days after surgery. RESULTS: The mean arterial pressure (MAP), heart rate (HR) and brain oxygenation were similar between groups at different time points (P>0.05). There were no significant differences in the operation time, time of anesthesia and intra-operative urine volume between groups. As compared to the C group, the blood loss and dose of propofol reduced significantly (P<0.05). After extubation, the respiratory frequency reduced and PaO2 increased markedly (P<0.05). After surgery, the time of thoracic tube indwelling and hospital stay reduced dramatically in the D group as compared to the C group (P<0.05). The QoR-15 score and MMSE score in the D group were markedly higher than in the C group (P<0.05). CONCLUSIONS: Dexmedetomidine can improve the post-operative recovery and mental status after RATS.

Adjusting Assistance Commensurates with Patient Effort During Robot-Assisted Upper Limb Training for a Patient with Spasticity After Cervical Spinal Cord Injury: A Case Report.

Limited evidence is available on optimal patient effort and degree of assistance to achieve preferable changes during robot-assisted training (RAT) for spinal cord injury (SCI) patients with spasticity. To investigate the relationship between patient effort and robotic assistance, we performed training using an electromyography-based robotic assistance device (HAL-SJ) in an SCI patient at multiple settings adjusted to patient effort. In this exploratory study, we report immediate change in muscle contraction patterns, patient effort, and spasticity in a 64-year-old man, diagnosed with cervical SCI and with American Spinal Injury Association Impairment Scale C level and C4 neurological level, who underwent RAT using HAL-SJ from post-injury day 403. Three patient effort conditions (comfortable, somewhat hard, and no-effort) by adjusting HAL-SJ's assists were set for each training session. Degree of effort during flexion and extension exercise was assessed by visual analog scale, muscle contraction pattern by electromyography, modified Ashworth scale, and maximum elbow extension and flexion torques, immediately before and after each training session, without HAL-SJ. The amount of effort during training with the HAL-SJ at each session was evaluated. The degree of effort during training can be set to three effort conditions as we intended by adjusting HAL-SJ. In sessions other than the no-effort setting, spasticity improved, and the level of effort was reduced immediately after training. Spasticity did not decrease in the training session using HAL-SJ with the no-effort setting, but co-contraction further increased during extension after training. Extension torque was unchanged in all sessions, and flexion torque decreased in all sessions. When performing upper-limb training with HAL-SJ in this SCI patient, the level of assistance with some effort may reduce spasticity and too strong assistance may increase co-contraction. Sometimes, a patient's effort may be seemingly unmeasurable; hence, the degree of patient effort should be further measured.

An assessment of early functional rehabilitation and hospital discharge in conventional versus robotic-arm assisted unicompartmental knee arthroplasty: a prospective cohort study.

AIMS: The objectives of this study were to compare postoperative pain, analgesia requirements, inpatient functional rehabilitation, time to hospital discharge, and complications in patients undergoing conventional jig-based unicompartmental knee arthroplasty (UKA) versus robotic-arm assisted UKA. PATIENTS AND METHODS: This prospective cohort study included 146 patients with symptomatic medial compartment knee osteoarthritis undergoing primary UKA performed by a single surgeon. This included 73 consecutive patients undergoing conventional jig-based mobile bearing UKA, followed by 73 consecutive patients receiving robotic-arm assisted fixed bearing UKA. All surgical procedures were performed using the standard medial parapatellar approach for UKA, and all patients underwent the same postoperative rehabilitation programme. Postoperative pain scores on the numerical rating scale and opiate analgesia consumption were recorded until discharge. Time to attainment of predefined functional rehabilitation outcomes, hospital discharge, and postoperative complications were recorded by independent observers. RESULTS: Robotic-arm assisted UKA was associated with reduced postoperative pain (p < 0.001), decreased opiate analgesia requirements (p < 0.001), shorter time to straight leg raise (p < 0.001), decreased number of physiotherapy sessions (p < 0.001), and increased maximum knee flexion at discharge (p < 0.001) compared with conventional jig-based UKA. Mean time to hospital discharge was reduced in robotic UKA compared with conventional UKA (42.5 hours (sd 5.9) vs 71.1 hours (sd 14.6), respectively; p < 0.001). There was no difference in postoperative complications between the two groups within 90 days' follow-up. CONCLUSION: Robotic-arm assisted UKA was associated with decreased postoperative pain, reduced opiate analgesia requirements, improved early functional rehabilitation, and shorter time to hospital discharge compared with conventional jig-based UKA.

Enhanced Recovery after Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review.

Enhanced recovery after surgery (ERAS) is an evidence-based approach to perioperative care of the surgical patient. A mounting body of literature in gynecologic surgery has demonstrated that ERAS improves postoperative outcomes, shortens hospital length of stay, and reduces cost without increasing complications or readmissions. Most of the existing literature has concentrated on open surgery, questioning if patients undergoing minimally invasive surgery also derive benefit. Our aim was to systematically review the literature on ERAS after minimally invasive gynecologic surgery (MIGS) with and without bowel surgery. Given the paucity of studies on ERAS in MIGS with bowel surgery (1 study), we expanded our search to include studies of ERAS in patients undergoing minimally invasive colorectal resections alone. Twelve studies were identified through an electronic database search of PubMed, Medline, and Ovid EMBASE. These studies included patients undergoing MIGS for benign and/or malignant indications and showed that ERAS pathways decreased length of stay and/or increased the proportion of same-day discharge surgeries, improved patient satisfaction, and reduced hospital costs while maintaining low postoperative complication and readmission rates. Although limited, data from a single study suggest that ERAS in MIGS with bowel surgery leads to shortened hospital stay, stable postoperative morbidity, and less readmissions. Although the variation between the published protocols underscores the need for standardization, existing literature supports the adoption of ERAS as safe and effective when planning MIGS.

Fisioterapia en la incontinencia urinaria severa y disfunción eréctil posprostatectomía: estudio de un caso / Physiotherapy in severe urinary incontinence and erectile dysfunction after prostatectomy: a case study

Antecedentes y objetivo: La prostatectomía radical se ha convertido en el gold standard para tratar el cáncer de próstata. Se han desarrollado nuevas técnicas quirúrgicas para intentar maximizar los resultados en la resección del tumor y minimizar las secuelas, naciendo así la prostatectomía radical robótica. Aunque parece mostrar unos mejores resultados, el porcentaje de pacientes con secuelas como la incontinencia urinaria y la disfunción eréctil sigue siendo importante. Se ha probado que la fisioterapia puede contribuir a la resolución de estas secuelas acortando los tiempos de curación en la prostatectomía abierta y en la laparoscópica. El objetivo de este trabajo es conocer los efectos del tratamiento de fisioterapia en las secuelas de la prostatectomía radical robótica. Descripción del caso: Paciente de 63 años intervenido de prostatectomía radical robótica por adenocarcinoma de próstata, Gleason 6 (3+3), bilateral. Al inicio del tratamiento el paciente presenta incontinencia muy severa, con una pérdida de 332g en el Pad test 1h y una disfunción severa con una puntuación de 5 en el cuestionario International Index of Erectile Function(IIEF-15). Intervención: Aplicación de un programa de fisioterapia que consiste en toma de conciencia, biofeedback barométrico y electroestimulación intracavitaria, de la musculatura suelo pélvico, realizado 3 días/semana con una duración de 1h durante 32 semanas. Resultados y discusión: El paciente alcanza la función eréctil a los 6 meses, con una puntuación de 26 en el IIEF-15 y la continencia a los 8 meses, con 0g de pérdida en el Pad test 1h

Background and objective: Radical prostatectomy has become the reference method for treating prostate cancer. New surgical techniques have been developed to try to maximize results in tumour resection and minimize sequelae, resulting in radical robotic prostatectomy. Although there appear to be better outcomes, there are still a significant percentage of patients with sequelae, such as urinary incontinence and erectile dysfunction. It has been shown that physiotherapy can contribute to the resolution of these sequelae by shortening healing times in open and laparoscopic prostatectomy. The aim of this study is to determine the effects of physiotherapy treatment on the sequelae of radical robotic prostatectomy. Case report: A 63-year-old patient underwent robotic radical prostatectomy for prostate adenocarcinoma, Gleason 6 (3+3), bilateral. At the beginning of the treatment, the patient had very severe incontinence, with a loss of 332g in the 1-h pad test, and a severe dysfunction with a score of 5 in the International Index of Erectile Function questionnaire (IIEF-15). Intervention: Application of a physiotherapy program consisting of awareness, barometric biofeedback, and intracavitary electrostimulation of the pelvic floor musculature, performed 3 days/week, 1h for 32 weeks. Results and discussion: The patient achieved erectile function at 6 months, with a score of 26 in the IIEF-15, and continence at 8 months, with 0g of loss in the 1-h pad test

Patient-reported quality of life recovery curves after robotic prostatectomy are similar across body mass index categories.

PURPOSE: To assess the impact of body mass index (BMI) on postoperative recovery curve of urinary and sexual function after robotic-assisted laparoscopic prostatectomy (RALP). We hypothesized that overweight and obese men have different recovery curves than normal weight men. MATERIALS AND METHODS: We reviewed preoperative and postoperative surveys from 691 men who underwent RALP from 2004-2014 in an integrated healthcare delivery system. Survey instruments included: sexual health inventory for men (SHIM), urinary behavior, leakage, and incontinence impact questionnaire (IIQ). A repeated measures analysis with autoregressive covariance structure was employed with linear splines with 2 knots for the time factor. We fit unadjusted and adjusted models and stratified by BMI (under/normal weight, overweight, and obese). Adjusted models included age, race/ethnicity, smoking status, diabetes, operation length, prostate-specific antigen, pathologic stage, nerve-sparing status, and surgery year. RESULTS: Mean age was 59 years. Most men were overweight (43%) and obese (42%). There were no significant differences in mean baseline SHIM, urinary behavior, leakage, and IIQ scores by BMI category. All groups had initial steep declines in urinary and sexual function in the first 3 months after RALP. There were no significant differences in postoperative urinary and sexual function score curves by BMI category. CONCLUSIONS: The pattern of urinary and sexual function recovery was similar across all BMI categories. Overweight and obese men may be counseled that urinary and sexual function recovery curves after surgery is similar to that of normal weight men.

Functional outcomes of clinically high-risk prostate cancer patients treated with robot-assisted radical prostatectomy: a multi-institutional analysis.

BACKGROUND: To ascertain 3-year urinary continence (UC) and sexual function (SF) recovery following robot-assisted radical prostatectomy (RARP) for clinically high-risk prostate cancer (PCa). METHODS: Retrospective analyses of a prospectively maintained database for 769 patients with D'Amico high-risk PCa undergoing RARP at two tertiary care centers in the United States and Europe between 2001 and 2014. The association between time since RARP and recovery of UC (defined as 0 pad/one safety liner per day) and SF (defined as sexual health inventory for men (SHIM) score ⩾17) was tested in separate preoperative and post-operative Cox-proportional hazards regression models. Sensitivity analyses were conducted using continence 0 pad per day and erection sufficient for intercourse as end points for UC and SF recovery, respectively. RESULTS: Mean age of the cohort was 62.3 years, and 62.1% harbored ⩾PT3a disease. Nerve sparing (unilateral or bilateral) RARP was performed in 87.7% of patients. Kaplan-Meier estimates of UC recovery at 12, 24 and 36 months after surgery was 85.2%, 89.1% and 91.2%, respectively, while 33.8, 52.3 and 69.0% of preoperatively potent men (preoperative SHIM ⩾17; n=548; 71.3%) recovered SF. Similar results were noted in sensitivity analyses. Patient age and year of surgery were associated with UC and SF recovery; additionally, preoperative SHIM score, degree of nerve sparing, pT3b-T4 disease and surgical margins were associated with SF recovery over the period of observation. CONCLUSIONS: Patients with D'Amico high-risk PCa treated with RARP may continue to recover UC and SF beyond 12 months of surgery and show promising outcomes at 3-year follow-up. Appropriate patient selection and counseling may aid in setting realistic expectations for functional recovery post RARP.

[Era of enhanced recovery after surgery and robotic gastric cancer surgery].

Enhanced recovery after surgery (ERAS) has been rapidly developing by combining several techniques with evidence-based adjustments, including preoperative education, preoperative carbohydrate loading, epidural or regional anesthesia, early initiation of enteral nutrition, ambulation and multi-modal pain management. The core part of ERAS is to reduce and reverse surgical stress and therefore greatly improve clinical outcome. Under the guidance of ERAS, perioperative management of robotic gastric cancer operation should follow the basic principles of ERAS and clinical pathway to maximize the advantages of the robotic surgery. ERAS protocol is safe and feasible for patients undergoing robotic radical gastrectomy and it can reduce surgical stress, shorten hospital stay, improve quality of life and does not increase complications, whose mechanism may be associated with the reduction of inflammation and insulin resistance, the decrease of resting energy exposure, and the protection of mitochondria function. It is worth emphasizing that it is very important to fully understand the changes of pathophysiology during perioperative period, to strictly implement the ERAS pathway based on optimized evidence-based medicine, to cooperate closely with the multidisciplinary team, to observe and manage the postoperative complications dynamically by systemic classification. The improvement of ERAS program on the outcome of patients should be summarized regularly and the new interventional strategies should be evaluated further according to the international standard.

Impact of postoperative phosphodiesterase type 5 inhibitor treatment on lower urinary tract symptoms after robot-assisted radical prostatectomy: a longitudinal study.

OBJECTIVE: This study aimed to assess the role of tadalafil, a phosphodiesterase type 5 inhibitor (PDE5-I), in recovery of lower urinary tract symptoms (LUTS) after robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: All patients treated with RARP between October 2010 and August 2013 were enrolled in this retrospective study on prospectively collected data. Patients were retrospectively divided into groups according to postoperative treatment: patients taking tadalafil twice weekly from 1 month to 6 months after RARP, and patients not taking tadalafil. The International Prostate Symptom Score (IPSS), the Overactive Bladder Symptom Score (OABSS) and urinary continence (UC) were assessed preoperatively (2 days before RARP) and at 1, 3, 6, 9 and 12 months after RARP. RESULTS: There was no difference in the overall IPSS score between the groups. At 6 and 9 months, the IPSS storage symptom scores were significantly lower in patients taking tadalafil than in patients not taking tadalafil. In patients with overactive bladder (OAB) before RARP (n = 22), no differences in the total scores of OABSS were seen between patients taking tadalafil and patients not taking tadalafil. On the other hand, in non-OAB patients before RARP (n = 68), at 3, 6 and 9 months, the total scores of OABSS were significantly lower in patients taking tadalafil than in patients not taking tadalafil. No differences in UC rates after surgery were seen between the groups. CONCLUSION: Postoperative tadalafil treatment may be temporarily effective for the recovery of the IPSS storage symptom scores and OABSS.

Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery.

OBJECTIVE: To estimate whether an enhanced recovery after surgery pathway facilitates early recovery and discharge in gynecologic oncology patients undergoing minimally invasive surgery. METHODS: This was a retrospective case-control study. Consecutive gynecologic oncology patients undergoing laparoscopic or robotic surgery between July 1 and November 5, 2014, were treated on an enhanced recovery pathway. Enhanced recovery pathway components included patient education, multimodal analgesia, opioid minimization, nausea prophylaxis as well as early catheter removal, ambulation, and feeding. Cases were matched in a one-to-two ratio with historical control patients on the basis of surgery type and age. Primary endpoints were length of hospital stay, rates of discharge by noon, 30-day hospital readmission rates, and hospital costs. RESULTS: There were 165 patients included in the final cohort, 55 of whom were enhanced recovery pathway patients. Enhanced recovery patients were more likely to be discharged on postoperative day 1 compared with patients in the control group (91% compared with 60%, P<.001, odds ratio 6.7, 95% confidence interval 2.46-18.04). Fifteen percent of enhanced recovery patients achieved discharge by noon compared with 4% of historical control patients (P=.03). Postoperative pain scores decreased (2.6 compared with 3.12, P=.03) despite a 30% reduction in opioid use. Average total hospital costs were decreased by 12% in the enhanced recovery group ($13,771 compared with $15,649, P=.01). Readmission rates, mortality, and reoperation rates did not differ between the two groups. CONCLUSION: An enhanced recovery pathway in patients undergoing gynecologic oncology minimally invasive surgery is associated with significant improvements in recovery time, decreased pain despite reduced opioid use, and overall lower hospital costs.

Robotic-assisted radical prostatectomy learning curve for experienced laparoscopic surgeons: does it really exist?

BACKGROUND: Robotic-assisted radical prostatectomy (RALP) is a minimally invasive procedure that could have a reduced learning curve for unfamiliar laparoscopic surgeon. However, there are no consensuses regarding the impact of previous laparoscopic experience on the learning curve of RALP. We report on a functional and perioperative outcome comparison between our initial 60 cases of RALP and last 60 cases of laparoscopic radical prostatectomy (LRP), performed by three experienced laparoscopic surgeons with a 200+LRP cases experience. MATERIALS AND METHODS: Between January 2010 and September 2013, a total of 60 consecutive patients who have undergone RALP were prospectively evaluated and compared to the last 60 cases of LRP. Data included demographic data, operative duration, blood loss, transfusion rate, positive surgical margins, hospital stay, complications and potency and continence rates. RESULTS: The mean operative time and blood loss were higher in RALP (236 versus 153 minutes, p<0.001 and 245.6 versus 202ml p<0.001). Potency rates at 6 months were higher in RALP (70% versus 50% p=0.02). Positive surgical margins were also higher in RALP (31.6% versus 12.5%, p=0.01). Continence rates at 6 months were similar (93.3% versus 89.3% p=0.43). Patient's age, complication rates and length of hospital stay were similar for both groups. CONCLUSIONS: Experienced laparoscopic surgeons (ELS) present a learning curve for RALP only demonstrated by longer operative time and clinically insignificant blood loss. Our initial results demonstrated similar perioperative and functional outcomes for both approaches. ELS were able to achieve satisfactory oncological and functional results during the learning curve period for RALP.

Robotic-assisted surgery versus open surgery in the treatment of rectal cancer: the current evidence.

The aim of this meta-analysis was to comprehensively compare the safety and efficacy of robotic-assisted rectal cancer surgery (RRCS) and open rectal cancer surgery (ORCS). Electronic database (PubMed, EMBASE, Web of Knowledge, and the Cochrane Library) searches were conducted for all relevant studies that compared the short-term and long-term outcomes between RRCS and ORCS. Odds ratios (ORs), mean differences, and hazard ratios were calculated. Seven studies involving 1074 patients with rectal cancer were identified for this meta-analysis. Compared with ORCS, RRCS is associated with a lower estimated blood loss (mean difference [MD]: -139.98, 95% confidence interval [CI]: -159.11 to -120.86; P < 0.00001), shorter hospital stay length (MD: -2.10, 95% CI: -3.47 to -0.73; P = 0.003), lower intraoperative transfusion requirements (OR: 0.52, 95% CI: 0.28 to 0.99, P = 0.05), shorter time to flatus passage (MD: -0.97, 95% CI = -1.06 to -0.88, P < 0.00001), and shorter time to resume a normal diet (MD: -1.71.95% CI = -3.31 to -0.12, P = 0.04). There were no significant differences in surgery-related complications, oncologic clearance, disease-free survival, and overall survival between the two groups. However, RRCS was associated with a longer operative time. RRCS is safe and effective.

Robot-assisted partial cystectomy with intraoperative frozen section examination: Evolution and evaluation of a novel technique.

PURPOSE: To describe a novel modification to robot-assisted partial cystectomy (RAPC) that allows for intraoperative surgical margin assessment by bimanual-examination and frozen-section analysis. MATERIALS AND METHODS: A total of 7 patients underwent RAPC at a single tertiary-care institution between 2008 and 2013. The technique evolved over the study-period and permitted real-time intraoperative surgical margin evaluation in the last 5 patients via bimanual-examination and frozen-section analysis, utilizing the GelPOINT platform (a hand-assist device). The GelPOINT platform was placed through a 4- to 5-cm vertical supraumbilical incision and allowed for rapid retrieval of the bladder specimen without compromising the pneumoperitoneum or prolonging the operative time. Perioperative, oncological and functional outcomes were evaluated; all patients had a minimum 12-month follow-up. At the time of last follow-up, a cross-sectional survey of patients was performed to evaluate regret/satisfaction utilizing validated questionnaires. RESULTS: The mean age was 72.5 years; 71.4% of the patients were men (n=5). All patients underwent RAPC for a malignant indication. The mean operative and console times were 291 and 217 minutes, respectively. No patient had a positive surgical margin. Mean length-of-stay was 1.7 days. At a median follow-up of 38.9 months, 1 patient experienced a local recurrence 6 months postsurgery. The only mortality was secondary to Lewy-body disease, in the same patient, 1 year postoperatively. Patient assessment of regret and satisfaction indicated 0% regret and 0% dissatisfaction. CONCLUSIONS: The 'modified' technique of RAPC is technically feasible, safe, and reproducible; further, RAPC leads to favorable oncological, functional and quality-of-life outcomes in patients eligible for partial cystectomy.

Robotic-assisted radical prostatectomy learning curve for experienced laparoscopic surgeons: does it really exist?

ABSTRACT Background Robotic-assisted radical prostatectomy (RALP) is a minimally invasive procedure that could have a reduced learning curve for unfamiliar laparoscopic surgeon. However, there are no consensuses regarding the impact of previous laparoscopic experience on the learning curve of RALP. We report on a functional and perioperative outcome comparison between our initial 60 cases of RALP and last 60 cases of laparoscopic radical prostatectomy (LRP), performed by three experienced laparoscopic surgeons with a 200+LRP cases experience. Materials and Methods Between January 2010 and September 2013, a total of 60 consecutive patients who have undergone RALP were prospectively evaluated and compared to the last 60 cases of LRP. Data included demographic data, operative duration, blood loss, transfusion rate, positive surgical margins, hospital stay, complications and potency and continence rates. Results The mean operative time and blood loss were higher in RALP (236 versus 153 minutes, p<0.001 and 245.6 versus 202ml p<0.001). Potency rates at 6 months were higher in RALP (70% versus 50% p=0.02). Positive surgical margins were also higher in RALP (31.6% versus 12.5%, p=0.01). Continence rates at 6 months were similar (93.3% versus 89.3% p=0.43). Patient’s age, complication rates and length of hospital stay were similar for both groups. Conclusions Experienced laparoscopic surgeons (ELS) present a learning curve for RALP only demonstrated by longer operative time and clinically insignificant blood loss. Our initial results demonstrated similar perioperative and functional outcomes for both approaches. ELS were able to achieve satisfactory oncological and functional results during the learning curve period for RALP.

Introducing an enhanced recovery programme to an established totally intracorporeal robot-assisted radical cystectomy service.

OBJECTIVE: The aim of this study was to assess the effect of introducing an enhanced recovery programme (ERP) to an established robot-assisted radical cystectomy (RARC) service. MATERIALS AND METHODS: Data were prospectively collected on 221 consecutive patients undergoing totally intracorporeal RARC between December 2003 and May 2014. The ERP was specifically designed to support an evolving RARC service, where increasing proportions of patients requiring radical cystectomy underwent RARC. Patient demographics and outcomes before and after implementation of the ERP were compared. The primary endpoint was length of stay (LOS). Secondary outcomes included age, American Society of Anesthesiologists (ASA) score, preoperative staging, operative time, complications and readmissions. Differences in outcomes between patients before and after implementation of ERP were tested with the Jonckheere-Terpstra trend test and quantile regression with backward selection. RESULTS: Following implementation of the ERP, the demographics of the patients (n = 135) changed, with median age increasing from 66 to 70 years (p < 0.01), higher ASA grade (p < 0.001), higher preoperative stage cancer (pT ≥ 2, p < 0.05) and increased likelihood of undergoing an ileal conduit diversion (p < 0.001). Median LOS before ERP was 9 days [interquartile range (IQR) 8-13 days] and after ERP was 8 days (IQR 6-10 days) (p < 0.001). ASA grade and neoadjuvant chemotherapy also affected LOS (p < 0.05 and p < 0.01, respectively). There was no significant difference in 30 day complication rates, readmission rates or 90 day mortality, with 59% experiencing complications before ERP implementation and 57% after implementation. The majority of complications were low grade. CONCLUSIONS: Patient demographics changed as the RARC service evolved from selected patients to a general service. Despite worsening demographics, LOS decreased following ERP implementation. This evidence-based ERP safely standardized perioperative care, resulting in decreased LOS and decreased variability in LOS.