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.

Case report: pure robot-assisted psoas hitch ureteral reimplantation for distal-ureteral stenosis.

Robot-assisted procedures are slowly invading minimally invasive urologic surgery. When superior visibility, meticulous dissection, or complex reconstruction is needed, robotic surgery may offer benefits over conventional laparoscopy. We report the use of the da Vinci robotic system for laparoscopic psoas hitch-supported ureteral reimplantation. We believe this procedure was facilitated technically compared with conventional laparoscopy.

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.

Robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of 184 cases.

OBJECTIVE: To evaluate the initial functional and oncologic results of 184 robot-assisted radical prostatectomies performed at our hospital. METHODS: A retrospective study was made of the first 184 consecutive robot-assisted radical prostatectomies performed at our hospital between February 2003 and December 2005. The procedures were performed by two surgeons who used the da Vinci robot with three robot arms. A transperitoneal approach was used in all patients. All patients had clinically organ-confined prostate cancer (< or =cT2c). The median follow-up was 6 mo. RESULTS: A positive surgical margin was found in 29 of the 184 patients (mean: 15.7%). The percentage positive surgical margins for the organ-confined (pT2) and non-organ-confined prostate cancers (pT3) were 2.5% and 38%, respectively. Ninety-five percent of patients were completely continent or wore one safety liner. Forty-three percent of the continent patients achieved complete continence within 28 d. Eighty-one percent of the patients who were younger than 60 yr and received a nerve-sparing procedure were potent and able to perform sexual intercourse. This percentage dropped to 51% in patients older than 60 yr. No major complications were encountered. CONCLUSIONS: The functional and oncologic results of this minimally invasive procedure seem very promising. Longer follow-up of the data and larger prospective studies are necessary to confirm these promising results.