Technical and anatomical challenges to approach robotic-assisted radical prostatectomy in patients with Urolift®

ABSTRACT Introduction Urolift® is a surgical modality to treat lower urinary tract symptoms (LUTS) in patients with enlarged prostates (1). However, the inflammatory process caused by the device usually displaces the prostate's anatomical landmarks and challenges surgeons performing robotic-assisted radical prostatectomy (RARP). In this video, we will illustrate several technical challenges in patients with Urolift ® who underwent RARP. Material and Methods We performed a video compilation with several surgical steps illustrating key aspects and critical details of the anterior bladder neck access, lateral bladder dissection from the prostate, and posterior prostate dissection to avoid ureteral and neural bundles injuries. Results We perform our RARP technique with our standard approach in all patients (2 -6). The beginning of the case is performed like every patient with an enlarged prostate. We first identify the anterior bladder neck and then complete its dissection with Maryland and Scissors. However, extra care must be taken in the anterior and posterior bladder neck approach due to the clips found during the dissection. The challenge starts when opening the lateral sides of the bladder until the base of the prostate. It is crucial to perform the bladder neck dissection beginning at the internal plane of the bladder wall. Such dissection is the easiest way to recognize the anatomical landmarks and potential foreign materials, such as clips, placed during previous surgeries. We cautiously work around the clip to avoid using cautery on the top of the metal clips because energy is transmitted from one edge to the other of the Urolift ®. This can be dangerous if the edge of the clip is close to the ureteral orifices. The clips are usually removed to minimize cautery conduction energy. Finally, after isolating and removing the clips, the prostate dissection and subsequent surgical steps are continued with our conventional technique. Before proceeding, we ensure that all clips are removed from the bladder neck to avoid complications during the anastomosis. Conclusions Robotic-assisted radical prostatectomy in patients with Urolift ® is challenging due to modified anatomical landmarks and intense inflammatory processes in the posterior bladder neck. When dissecting the clips placed next to the base of the prostate, it is crucial to avoid cautery because energy conduction to the other edge of the Urolift ® can cause thermal damage to the ureters and neural bundles.

Comparing the outcomes of robotic assisted radical prostatectomy in black and white men: Experience of a high-volume center

ABSTRACT Background: Global cancer incidence ranks Prostate Cancer (CaP) as the second highest overall, with Africa and the Caribbean having the highest mortality. Previous literature suggests disparities in CaP outcomes according to ethnicity, specifically functional and oncological are suboptimal in black men. However, recent data shows black men achieve post radical prostatectomy (RP) outcomes equivalent to white men in a universally insured system. Our objective is to compare outcomes of patients who self-identified their ethnicity as black or white undergoing RP at our institution. Materials and methods: From 2008 to 2017, 396 black and 4929 white patients underwent primary robotic-assisted radical prostatectomy (RARP) with a minimum follow-up of 5 years. Exclusion criteria were concomitant surgery and cancer status not available. A propensity score (PS) match was performed with a 1:1, 1:2, and 1:3 ratio without replacement. Primary endpoints were potency, continence recovery, biochemical recurrence (BCR), positive surgical margins (PSM), and post-operative complications. Results: After PS 1:1 matching, 341 black vs. 341 white men with a median follow-up of approximately 8 years were analyzed. The overall potency and continence recovery at 12 months was 52% vs 58% (p=0.3) and 82% vs 89% (p=0.3), respectively. PSM rates was 13.4 % vs 14.4% (p = 0.75). Biochemical recurrence and persistence PSA was 13.8% vs 14.1% and 4.4% vs 3.2% respectively (p=0.75). Clavien-Dindo complications (p=0.4) and 30-day readmission rates (p=0.5) were similar. Conclusion: In our study, comparing two ethnic groups with similar preoperative characteristics and full access to screening and treatment showed compatible RARP results. We could not demonstrate outcomes superiority in one group over the other. However, this data adds to the growing body of evidence that the racial disparity gap in prostate cancer outcomes can be narrowed if patients have appropriate access to prostate cancer management. It also could be used in counseling surgeons and patients on the surgical intervention and prognosis of prostate cancer in patients with full access to gold-standard screening and treatment.

Step-by-step optimisation of robotic-assisted radical prostatectomy using augmented reality

ABSTRACT Introduction: Surgical training will be complemented by digitalisation, as the COVID 19 pandemic continues (1). Proximie is an augmented reality (AR) platform that can display up to 4 native camera views, with live or semi live telementoring. It can optimise ergonomics of the surgeon at the console (2), and robotic instrument orientation. We describe the utilisation of Proximie as a step-by-step guide in a robotic assisted radical prostatectomy (RARP). Surgical Technique: Author V. P. performed a transperitoneal multiport da Vinci Xi RARP with the Proximie platform: a laptop computer, multiple HD webcams, microphones and speakers. Using an HDMI cable to the Intuitive Surgical tower, output display from the console and an additional laparoscopic tower is shown. Each webcam was mounted to the side armrests of the console, directed at the surgeon's hands. An independent 'drop in' laparoscope via an additional 5mm left upper quadrant port was utilised. Observers can visualise the AR platform's recordings on a laptop and/or smartphone. A PTZ (pan-tilt-zoom) camera can capture the operating room, bedside assistant, ports and patient position. Our video demonstrates three of four camera views for posture, forearm, wrist, hand, and finger orientation, relative to the translated robotic steps. A pincer grasp of the endowrist manipulator during anastomosis allows optimal robotic wrist rotation. The second laparoscopic camera view demonstrated intracorporeal angles of robotic arm and bedside assistant's instrument position for critical steps such as nerve sparing and anastomosis (3). The console time was 100 minutes, no intraoperative complications, or delay in image transmission occurred with utilising the platform. Considerations: An AR platform can create deeper learning for RARP in real time or recorded sessions. Two-way verbal and visual communication with ability to annotate on screen, allows long distance mentoring. The platform's utility can be accessed in anywhere, to project surgeons beyond their immediate environment. This allows for democratisation of access to high volume institutions and their evolution of techniques (4), to assist patients globally. Potential developments are artificial intelligence (AI) networks analysing repository of such recorded data, to identify intraoperative hand motion and robotic instrument tracking. AR is a pertinent building block to enhance robotic training, skill dissemination, precision medicine (5) and surgery overall.

Minimally invasive lymphocele drainage using the Da Vinci® single port platform: step-by- step technique

ABSTRACT Background: Reports in the literature describe lymphocele formation in up to half of patients following pelvic lymph node dissection (PLND) (1) in robotic-assisted radical prostatectomy (RARP), with 1-2% requiring intervention (2). The advantage of surgical approach is permanent excision of the lymphocele capsule and fewer days with pelvic drains compared to percutaneous drainage. This study aims to describe the step-by-step surgical management of symptomatic lymphoceles using a less invasive robotic platform, the Da Vinci® Single Port (SP). Material and Methods: We describe the technique of lymphocelectomy and marsupialization with the Da Vinci® SP for symptomatic lymphocele. For this study, several treatment modalities for symptomatic lymphoceles were available, including percutaneous drainage, sclerosing agents, and surgical marsupialization. All the data for this study were obtained through the procedure via Da Vinci® SP. Results: Operative time for the case was 84 minutes. Blood loss was 25ml. No intra- or post- operative complications were reported. The patient had his drain removed in under 24 hours after surgery. The mean follow-up period was 7.7 months. There were no complications or lymphocele recurrence. Conclusion: Da Vinci® SP lymphocelectomy is safe and feasible with satisfactory outcomes. The SP enables definitive treatment of the lymphocele sac (3), reducing the number of days with abdominal drains and allows further decrease in surgical invasiveness with fewer incisions and better cosmesis.