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Techniques of nerve-sparing and potency outcomes following robot-assisted laparoscopic prostatectomy
Chauhan, Sanket;Coelho, Rafael F.;Rocco, Bernardo;Palmer, Kenneth J.;Orvieto, Marcelo A.;Patel, Vipul R.;
International braz j urol , 2010, DOI: 10.1590/S1677-55382010000300002
Abstract: purpose: nerve sparing radical prostatectomy is the gold standard for the treatment of prostate cancer. over the past decade, more and more surgeons and patients are opting for a robot-assisted procedure. the purpose of this paper is to briefly review different techniques and outcomes of nerve sparing robot assisted laparoscopic prostatectomy (ralp). materials and methods: we performed a medline search from 2001 to 2009 using the keywords “robotic prostatectomy”, “cavernosal nerve”, “pelvic neuroanatomy”, “potency”, “outcomes” and “comparison”. extended search was also performed using the references from these articles. results: several techniques of nerve sparing are available in literature for ralp, which have been described in this manuscript. these include, “the veil of aphrodite”, “athermal retrograde neurovascular release”, “clipless antegrade nerve sparing” and “clipless cautery free technique”. the comparative and the non comparative series showing outcomes of ralp have been described in the manuscript. conclusions: the basic principles for nerve sparing revolve around minimal traction, athermal dissection, and approaching the correct planes. it has not been documented if any one technique is better than the other. regardless of technique, patient selection, wise clinical judgment and a careful dissection are the keys to achieve optimal oncological outcomes following ralp.
Robot-Assisted Laparoscopic Radical Prostatectomy: Technique and Outcomes of 700 Cases  [cached]
John R. Carlucci,Fatima Nabizada-Pace,David B. Samadi
International Journal of Biomedical Science , 2009,
Abstract: Background: Robotic prostatectomy techniques are evolving rapidly as the procedure gains popularity and continues to be compared to the gold standard of open retropubic radical prostatectomy. Our objective is to report the operative technique and outcomes of 700 consecutive robotic radical prostatectomies performed by a single surgeon at Mount Sinai Medical Center between May 2007 and October 2008. Data was prospectively collected in an Internal Review Board (IRB)-approved database. Surgical Procedure: Key aspects of our technique include 1) dissection of the bladder neck first; 2) minimal to no use of cautery from posterior bladder neck dissection onward; 3) leaving endopelvic fascia intact until after neurovascular bundles dissected; 4) preservation of a wide margin of endopelvic fascia; 5) posterior dissection and nerve-sparing in a medial to lateral direction; 6) cold transection of the dorsal venous complex without prior ligation; and 7) posterior bladder neck reconstruction. Results: Mean OR time from skin incision to skin closure was 124 minutes [48-266]; mean robotic time was 88 minutes [36-190]. Mean EBL was 69.3ml [5-400]. Mean and median length of stay was 1 day. Overall complication rate was 3.3% with no mortalities and no conversions to open or laparoscopic approaches. The overall positive margin rate (PMR) was 11.9%. PMR was 1.4% for pT2a, 0% for pT2b, 8.3% for pT2c, 39.7% for pT3a, and 56.7% for pT3b. Biochemical recurrence rate at one year was 1.7%. Continence rate by 12 months was 94%. Potency rate by 12 months was 83%. Conclusions: Both perioperative and postoperative outcomes of our series of robotic prostatectomies performed by a single surgeon at Mount Sinai Medical Center demonstrate the superb outcomes that can be achieved through this modality of treatment.
Robot-assisted laparoscopic partial nephrectomy: Current review of the technique and literature  [cached]
Singh Iqbal
Journal of Minimal Access Surgery , 2009,
Abstract: Aim: To visit the operative technique and to review the current published English literature on the technique, and outcomes following robot-assisted laparoscopic partial nephrectomy (RPN). Materials and Methods: We searched the published English literature and the PubMed (TM) for published series of ′robotic partial nephrectomy′ (RPN) using the keywords; robot, robot-assisted laparoscopic partial nephrectomy, laparoscopic partial nephrectomy, partial nephrectomy and laparoscopic surgery. Results: The search yielded 15 major selected series of ′robotic partial nephrectomy′; these were reviewed, tracked and analysed in order to determine the current status and role of RPN in the management of early renal neoplasm(s), as a minimally invasive surgical alternative to open partial nephrectomy. A review of the initial peri-operative outcome of the 350 cases of select series of RPN reported in published English literature revealed a mean operating time, warm ischemia time, estimated blood loss and hospital stay, of 191 minutes, 25 minutes, 162 ml and 2.95 days, respectively. The overall computed mean complication rate of RPN in the present select series was about 7.4%. Conclusions: RPN is a safe, feasible and effective minimally invasive surgical alternative to laparoscopic partial nephrectomy for early stage (T 1 ) renal neoplasm(s). It has acceptable initial renal functional outcomes without the increased risk of major complications in experienced hands. Prospective randomised, controlled, comparative clinical trials with laparoscopic partial nephrectomy (LPN) are the need of the day. While the initial oncological outcomes of RPN appear to be favourable, long-term data is awaited.
Long-Term Outcomes Following Laparoscopic and Abdominal Supracervical Hysterectomies  [PDF]
Marit Lieng,Anne Birthe L?mo,Erik Qvigstad
Obstetrics and Gynecology International , 2010, DOI: 10.1155/2010/989127
Abstract: Long-term outcomes, in terms of cervical stump symptoms and overall patient satisfaction, were studied in women both after abdominal (SAH) and laparosocopic (LSH) supracervical hysterectomies. Altogether, 134 women had SAH and 315 women LSH during 2004 and 2005 at our department. The response rate of this retrospective study was 79%. Persistent vaginal bleeding after the surgery was reported by 17% in the SAH group and 24% in the LSH group. Regular bleeding was reported by only 8% in both study groups, and the women rarely found the bleeding bothersome. The women reported a significant pain reduction after the surgery, but women having a hysterectomy because of pain and/or endometriosis should be informed about the possibility of persistent symptoms. The overall patient satisfaction after both procedures was high, but the patients should have proper preoperative information about the possibility of cervical stump symptoms after any supracervical hysterectomy. 1. Introduction Hysterectomy is the ultimate treatment for women suffering from symptomatic fibroids, abnormal uterine bleeding and uterine malignancy and is one of the most frequent performed surgical procedures [1, 2]. There is no universal agreement about the optimal method of hysterectomy—abdominal, laparoscopic, or vaginal—and there is a question whether the cervix should be removed as a routine part of the hysterectomy. The world’s first successful supracervical abdominal hysterectomy (SAH) was performed in 1853 by Gilman Kimball in USA. Since then, the advantages and disadvantages of supracervical versus total hysterectomy technique have been discussed, with variable enthusiasm in different time periods and between countries. More recently, there has been a swing back to supracervical, with marked geographic variations [3–6]. In Scandinavia, the ratio of supracervical to total hysterectomy is traditionally high. At our department in Oslo, Norway, supracervical hysterectomy is the recommended procedure for women with benign conditions requiring hysterectomy and with no previous history of cervical dysplasia. Although laparoscopic supracervical hysterectomy (LSH) has gradually replaced abdominal hysterectomy, SAH is still performed in women where laparoscopic or vaginal approach is not feasible, mainly due to significant enlarged uterus [7]. Opponents of supracervical hysterectomy, either it is performed open or by a laparoscopic approach, often seem to be concerned with the risk of cervical stump symptoms such as vaginal bleeding and pelvic pain following the hysterectomy, causing patient
Comparison of Perioperative Outcomes of Total Laparoscopic and Robotically Assisted Hysterectomy for Benign Pathology during Introduction of a Robotic Program  [PDF]
Gokhan Sami Kilic,Gradie Moore,Ayman Elbatanony,Carmen Radecki,John Y. Phelps,Mostafa A. Borahay
Obstetrics and Gynecology International , 2011, DOI: 10.1155/2011/683703
Abstract: Study Objective. Prospectively compare outcomes of robotically assisted and laparoscopic hysterectomy in the process of implementing a new robotic program. Design. Prospectively comparative observational nonrandomized study. Design Classification. II-1. Setting. Tertiary caregiver university hospital. Patients. Data collected consecutively 24 months, 34 patients underwent laparoscopic hysterectomy, 25 patients underwent robotic hysterectomy, and 11 patients underwent vaginal hysterectomy at our institution. Interventions. Outcomes of robotically assisted, laparoscopic, and vaginal complex hysterectomies performed by a single surgeon for noncancerous indications. Measurements and Main Results. Operative times were minutes for laparoscopic, minutes for robotic, and minutes for vaginal ( ). Estimated blood loss for patients undergoing laparoscopic surgery was ?cc, ?cc for robotic surgery, and ?cc for vaginal surgery ( ). The mean length of stay ranged from 1.8 to 2.3 days for the 3 methods. Association was significant for uterine weight ( ) among surgery methods. Conclusion. Robotically assisted hysterectomy is feasible with low morbidity, a shorter hospital stay, and less blood loss. This suggests that robotic assistance facilitates a minimally invasive approach for patients with larger uterine size even during implementing a new robotic program. 1. Introduction Hysterectomy is the second most commonly performed surgical procedure in the United States after cesarean delivery [1]. The Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project reported 518,828 hysterectomies for benign disease in 2005 [2]. A stable rate of 5.1–5.8 hysterectomies per 1,000 female civilian US residents was reported between 1995 and 1999 [3]. The same recent analysis of Healthcare Cost and Utilization Project data showed that abdominal hysterectomy was performed in 64% of cases, followed by the vaginal route in 22% of cases and the laparoscopic route in 14%. Robotic-assisted hysterectomy is emerging as a new technique for hysterectomy [2]. Improved visualization and dexterity in robotic surgery may offer some advantages over conventional laparoscopy [4, 5], and shorter hospital stays and decreased blood loss may also be advantages over laparotomy [6, 7]. Overall, minimally invasive surgical techniques for performing hysterectomy have been shown to reduce patient morbidity and shorten hospital stays [8, 9]. A robotic system (da Vinci Surgical System, Intuitive Surgical, Inc., Sunnyvale, CA) is designed to address many of the limitations of conventional
A Comparison of Radical Perineal, Radical Retropubic, and Robot-Assisted Laparoscopic Prostatectomies in a Single Surgeon Series  [PDF]
Moben Mirza,Kevin Art,Logan Wineland,Ossama Tawfik,J. Brantley Thrasher
Prostate Cancer , 2011, DOI: 10.1155/2011/878323
Abstract: Objective. We sought to compare positive surgical margin rates (PSM), estimated blood loss (EBL), and quality of life outcomes (QOL) among perineal (RPP), retropubic (RRP), and robot-assisted laparoscopic (RALP) prostatectomies. Methods. Records from 463 consecutive men undergoing RPP (92), RRP (180), or RALP (191) for clinically localized prostate cancer were retrospectively reviewed. Age, percent tumor volume, Gleason score, stage, EBL, PSM, and QOL using the expanded prostate cancer index composite (EPIC) were compared. Results. PSM were similar when adjusted for stage, grade, and volume. EBL was significantly less in the RALP (189?ml) group compared to both RPP (475?ml) and RRP (999?ml) groups. When corrected for nerve sparing, there were no differences in erectile function and sexual function amongst the three groups. Urinary summary and pad usage scores showed no significant differences. Conclusion. RPP, RRP, and RALP offer similar surgical and QOL outcomes. RALP and RPP demonstrate less EBL compared to RRP. 1. Introduction Radical prostatectomy remains the most commonly used treatment for clinically localized prostate cancer and can be performed by a variety of techniques. First performed by Young in 1904, the radical perineal prostatectomy (RPP) has been a proven technique for over 100 years. However, in the early 1980s, modifications to the radical retropubic prostatectomy (RRP) were introduced. RRP became the most popular surgical option and gained wider acceptance with the introduction of the nerve sparing technique by Walsh [1]. Large series comparing RRP with RPP have generally shown similar outcomes, except decreased blood loss associated with RPP [2, 3]. In more recent years, robot-assisted laparoscopic prostatectomy (RALP) and laparoscopic radical prostatectomy (LRP) have been introduced as minimally invasive techniques with associated benefits of shorter recovery periods, decreased postoperative pain, and smaller incisions [4]. There are multiple studies which have compared surgical outcomes between the different techniques including rates of positive surgical margin (PSM) among the different surgical modalities. Several studies have shown decreased PSM rates with RALP compared to RRP, yet others have demonstrated no advantage when RALP is used [5–8]. Regardless of their findings, these studies many times have inherent limitations introduced when data from multiple surgeons is compiled. This also creates potential bias in patient selection between the different surgical modalities which may impact results. Also, the popularity of RPP
Robotic assisted Laparoscopic partial Nephrectomy for suspected Renal Cell Carcinoma: Retrospective review of surgical outcomes of 35 Cases
Sam B Bhayani, Nitin Das
BMC Surgery , 2008, DOI: 10.1186/1471-2482-8-16
Abstract: Patient records and databases were reviewed for 35 consecutive patients undergoing RPN. Clinical, pathological, and radiographic data were obtained. The data was deidentified.Thirty five patients successfully underwent RPN. An additional 2 patients were converted to other nephron sparing procedures. Mean tumor size was 2.8 cm, and mean OR time was 142 minutes. Mean warm ischemia time was 20 minutes. All margins were negative. There were 4 complications, and no patients required reoperation.Robotic partial nephrectomy can produce excellent initial results. Further studies should be performed to compare the outcomes to laparoscopic and open operations.The small suspicious renal mass may be treated with a variety of modalities. Open radical nephrectomy is the traditional treatment for a renal neoplasm, but open partial nephrectomy has evolved into a standard of care, with the obvious advantage of sparing the kidney.[1] In the 1990s laparoscopic approaches to partial nephrectomy were developed.[2,3] The laparoscopic partial nephrectomy has been performed in centers of excellence with reasonable results.[4] However, the operation has also been thought to be technically advanced secondary to the laparoscopic reconstructive skills necessary to perform the procedure quickly while the kidney is under warm ischemia.Robotic surgical assistance has been used to perform complex reconstructive procedures in a minimally invasive fashion. Robotic radical prostatectomy has become the prime example in which a complex open procedure may be reproduced with robotic assistance in a minimally invasive fashion.[5] The da Vinci robot (Intuitive Surgical, Sunnyvale, CA, USA) allows ease of intracorporeal dissection and suturing secondary to the wristed and articulating instrumentation. To date, the robotic system has been sparsely reported as an adjunct to laparoscopic partial nephrectomy. [6-11] In this series, we report the outcomes of 35 patients undergoing robotic assisted laparoscopic p
Pure Laparoscopic and Robot-Assisted Laparoscopic Reconstructive Surgery in Congenital Megaureter: A Single Institution Experience  [PDF]
Weijun Fu, Xu Zhang, Xiaoyi Zhang, Peng Zhang, Jiangping Gao, Jun Dong, Guangfu Chen, Axiang Xu, Xin Ma, Hongzhao Li, Lixin Shi
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0099777
Abstract: To report our experience of pure laparoscopic and robot-assisted laparoscopic reconstructive surgery in congenital megaureter, seven patients (one bilateral) with symptomatic congenital megaureter underwent pure laparoscopic or robot-assisted laparoscopic surgery. The megaureter was exposed at the level of the blood vessel and was isolated to the bladder narrow area. Extreme ureter trim and submucosal tunnel encapsulation or papillary implantations and anti-reflux ureter bladder anastomosis were performed intraperitoneally by pure laparoscopic or robot-assisted laparoscopic surgery. The clinical data of seven patients after operation were analyzed, including the operation time, intraoperative complications, intraoperative bleeding volumes, postoperative complications, postoperative hospitalization time and pathological results. All of the patients were followed. The operation was successfully performed in seven patients. The mean operation times for pure laparoscopic surgery and robotic-assistant laparoscopic surgery were 175 (range: 150–220) and 187 (range: 170–205) min, respectively, and the mean operative blood loss volumes were 20 (range: 10–30) and 28.75 (range: 15–20) ml, respectively. There were no intraoperative complications. The postoperative drainage time was 5 (range: 4–6) and 5.75 (range: 5–6) d, respectively, and the indwelling catheter time was 6.33 (range: 4–8) d and 7 (range: 7–7) d, respectively. The postoperative hospitalization time was 7.67 (range: 7–8) d and 8 (range: 7–10) d, respectively. There was no obvious pain, no secondary bleeding and no urine leakage after the operation. Postoperative pathology reports revealed chronic urothelial mucosa inflammation. The follow-up results confirmed that all patients were relieved of their symptoms. Both pure laparoscopic and robot-assisted laparoscopic surgery using different anti-reflux ureter bladder anastomoses are safe and effective approaches in the minimally invasive treatment of congenital megaureter.
Robot-Assisted Laparoscopic Radical Prostatectomy in the Morbidly Obese Patient  [PDF]
Jennifer Yates,Ravi Munver,Ihor Sawczuk
Prostate Cancer , 2011, DOI: 10.1155/2011/618623
Abstract: Introduction. Obesity and prostate cancer are among the more common health issues affecting men in the United States. Methods. We retrospectively reviewed morbidly obese (BMI ≥ 40?kg/m2) patients undergoing RALP between 2004–2009 at our institution. Parameters including operative time, estimated blood loss, hospital stay, pathology, and complication rate were examined. Results. A total of 15 patients were included, with a mean BMI of 43?kg/m2. Mean preoperative PSA was 5.78?ng/dL, and Gleason score was 6.6. Mean operative time was 163 minutes, and mean estimated blood loss was 210?mL. The mean hospital stay was 1.3 days. Positive margins were noted in 2 (13%) patients, each with pT3 disease. There were no blood transfusions, open conversions, or Clavien Grade II or higher complications. Conclusions. In our experience, RALP is feasible in morbidly obese patients. We noted several challenges in this patient population which were overcome with modification of technique and experience. 1. Introduction The prevalence of obesity in the United States has increased over the past few decades. Recently, the National Health and Nutrition Examination Survey (NHANES) reported an age-adjusted prevalence of obesity in 2007 and 2008 to be 33.8% in men and 35.5% in women [1]. While in past years the prevalence of obesity has increased dramatically, it appears that the rate of increase may be slowing. The World Health Organization (WHO) definition of obesity is based on body mass index (BMI), and includes Grade I (BMI between 30 and 34.9?kg/m2), Grade II (BMI between 35?kg/m2 and 39.9?kg/m2), and Grade III (BMI of 40?kg/m2 and higher). Obesity contributes to a number of health conditions, including diabetes mellitus, hypertension, osteoarthritis, and some malignancies [2]. In regards to prostate cancer, some data suggests that obese patients may have less favorable disease pathology [3–5]. Obesity can make any surgical procedure more challenging and increase the risks of morbidity. The introduction of robot-assisted laparoscopic radical prostatectomy (RALP) can help overcome some of these technical difficulties, but also introduces other procedural challenges. Several institutions have reported experience in the obese population with open radical retropubic prostatectomy (RRP), radical perineal prostatectomy (RPP), and minimally invasive radical prostatectomy (MIRP), including laparoscopic radical prostatectomy (LRP), and RALP [6–23]. Many of the patients included in these studies meet the criteria for Class I or Class II obesity, with a lower incidence of Class III
Robot-assisted radical prostatectomy: surgical, oncological, and functional outcomes  [cached]
U?ur Boylu,Cem Ba?ata?,Turgay Turan,Fikret Fatih ?nol
Turkish Journal of Urology , 2012,
Abstract: Objective: To evaluate the surgical, oncological, and functional outcomes of robot-assisted radical prostatectomy.Materials and Methods: Between 2008 and 2011, a total of 203 patients with localized prostate cancer underwent robot-assisted radical prostatectomy. Of these patients, 150 were included into the study and were followed for a minimum of 1 year. Body mass index, IIEF-5 score, positive surgical margin rates, operative times, estimated blood loss, transfusion rates, biochemical recurrence rates, and length of hospital stay were noted. The continence and potency rates were evaluated at 3, 6, 9, and 12 months.Results: The mean operative time was 156 min. The mean blood loss was 220 mL. Bilateral nerve sparing was performed in 112, whereas a unilateral nerve sparing technique was used in 12 patients. A conversion to open surgery occurred in 1 patient due to excessive bleeding. The drain was removed after a mean duration of 2 days. The mean length of stay was 3.9 days. The urethral catheter was removed in a mean of 8.5 days. There were 20 grade 2, 5 grade 3, 2 grade 4 and 1 grade 5 complications (a total of 28 complications).Conclusion: Robot-assisted radical prostatectomy is an effective and safe minimally invasive approach in the treatment of localized prostate cancer. It is a strong alternative to conventional techniques with respect to its surgical, oncological, and functional outcomes.
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