Outcomes of Salvage Robotic-assisted Radical Prostatectomy in the last decade: systematic review and perspectives of referral centers

ABSTRACT Purpose: Salvage robotic-assisted radical prostatectomy (S-RARP) has gained prominence in recent years for treating patients with cancer recurrence following non-surgical treatments of Prostate Cancer. We conducted a systematic literature review to evaluate the role and outcomes of S-RARP over the past decade. Materials and Methods: A systematic review was conducted, encompassing articles published between January 1st, 2013, and June 1st, 2023, on S-RARP outcomes. Articles were screened according to PRISMA guidelines, resulting in 33 selected studies. Data were extracted, including patient demographics, operative times, complications, functional outcomes, and oncological outcomes. Results: Among 1,630 patients from 33 studies, radiotherapy was the most common primary treatment (42%). Operative times ranged from 110 to 303 minutes, with estimated blood loss between 50 to 745 mL. Intraoperative complications occurred in 0 to 9% of cases, while postoperative complications ranged from 0 to 90% (Clavien 1-5). Continence rates varied (from 0 to 100%), and potency rates ranged from 0 to 66.7%. Positive surgical margins were reported up to 65.6%, and biochemical recurrence ranged from 0 to 57%. Conclusion: Salvage robotic-assisted radical prostatectomy in patients with cancer recurrence after previous prostate cancer treatment is safe and feasible. The literature is based on retrospective studies with inherent limitations describing low rates of intraoperative complications and small blood loss. However, potency and continence rates are largely reduced compared to the primary RARP series, despite the type of the primary treatment. Better-designed studies to assess the long-term outcomes and individually specify each primary therapy impact on the salvage treatment are still needed. Future articles should be more specific and provide more details regarding the previous therapies and S-RARP surgical techniques.

Perioperative outcomes of robotic-assisted versus video-assisted thoracoscopic atypical segmentectomy for early-stage non-small cell lung cancer: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective     To compare the perioperative outcomes of atypical segmentectomy between robotic-assisted thoracoscopic surgery (RATS) and conventional video-assisted thoracoscopic surgery (VATS) in early-stage non-small cell lung cancer (NSCLC). Methods    The data of patients who underwent minimally invasive anatomic atypical segmentectomy in our hospital from October 2016 to December 2021 were collected. These patients were divided into a RATS group and a VATS group according to the operation method. Propensity score (PS) matching was used to select patients with close clinical baseline characteristics, and the perioperative results of the two groups were compared. Results    A total of 1 048 patients were enrolled, including 320 males and 728 females, with a mean age of 53.51±11.13 years. There were 277 patients in the RATS group and 771 patients in the VATS group. After 1∶1 PS matching, 277 pairs were selected. Both groups were well balanced for age, sex, smoking history, body mass index, Charlson comorbidity index, pulmonary function, tumor size, tumor location, and histological type. All patients were R0 resection, and there were no deaths within 30 days after surgery. The RATS group had shorter operative time [85 (75, 105) min vs. 115 (95, 140) min, P<0.001] and less blood loss [50 (30, 100) mL vs. 60 (50, 100) mL, P=0.001]. There were no statistical differences between the two groups in lymph node resection, conversion to thoracotomy, thoracic drainage time, total amount of thoracic drainage or postoperative complications (P>0.05). Conclusion    Both RATS and VATS atypical segment-ectomies are safe and feasible for early-stage NSCLC. RATS can effectively shorten the operative time, and reduce blood loss.

Analysis of the feasibility and safety of repair of ureteral stricture with oral mucosal graft / 中华泌尿外科杂志

Objective:To summarize and analyze the current application status of oral mucosal graft (OMG) technique in the repair of ureteral strictures in China, and clarify the feasibility, safety and effectiveness of this technique.Methods:The 175 patients who underwent repair of ureteral stricture using oral mucosal patches from June 2015 to February 2022 were etrospectively analyzed in 14 medical centers in China, including 49 cases in Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 32 cases in Affiliated Seventh Medical Center of PLA General Hospital, 3 cases in The Second Hospital of Anhui Medical University, 6 cases in The First Affiliated Hospital of Zhengzhou University, 56 cases in Peking University First Hospital, 3 cases in Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 cases in Shanghai Sixth People' s Hospital, 4 cases in General Hospital of Estern Theater Command, 4 cases in Lanzhou University Second Hospital, 2 cases in Guizhou Province People 's Hospital, 2 cases in Peking University People' s Hospital, 5 cases in Jinzhou First People's Hospital, 5 cases in The First Affiliated Hospital of Wannan Medical College, 1 case in Shandong Provincial Hospital. In this study, 127 patients (72.6%) used lingual mucosal patches, 32(18.3%) labial mucosa, and 16(9.1%) buccal mucosa. The surgical approach for OMG ureteral reconstruction was mainly minimally invasive, with robot-assisted laparoscopy in 84 patients (48.0%), traditional laparoscopic surgery in 87 patients (49.7%), and open surgery in only 4 patients (2.3%). There were 133 males and 42 females with an average age of (35.0±17.2) years. The mean body mass index (BMI) and stenosis length were (23.1±4.1) kg/m 2 and (4.7±1.8) cm, respectively. The stricture was located in the left ureter in 116 patients, right ureter in 58 case and bilateral ureter in 1 case. The most common causes of ureteral stricture were endoscopic surgery in 88(50.3%)patients, congenital stricture in 55(31.4%)patients, failed ureteroplasty in 29(16.6%)patients, history of extracorporeal shock wave lithotripsy in 13(7.4%)patients, radiotherapy history in 3(1.7%)patients and other causes in 6(3.4%)patients. Strictures were mainly located in the upper ureter, accounting for 61.7% (108/175 cases), followed by 36.0% (63/175) at the ureteropelvic junction and 2.3%(4/175)in the middle ureter. According to the surgical methods, the patients were divided into robot-assisted laparoscopic surgery group ( n=84), traditional laparoscopic surgery group ( n=87)and open surgery group ( n=4). Subgroup analysis of patients in robot-assisted laparoscopic and traditional laparoscopic surgery groups was performed. There were no significant difference in preoperative data between the two groups except for age (32.0±18.3) years vs.(37.0±15.9)years, P=0.040], BMI[(22.5±4.3)kg/m 2 vs. (23.7±3.6)kg/m 2, P=0.028], and etiology of stenosis [endoscopic injury, 34(40.5%) vs. 53(60.9%), P=0.012]. Preoperative hydronephrosis and stricture length were assessed by CTU and ureterography. Ureterography 7-9 weeks after surgery showed patency of the reconstructed segment, or no recurrence of hydronephrosis was judged as success. Evaluate the operation method, operation time, success rate, length of OMG in repairing ureteral stricture between laparoscopic and robot-assisted groups. Results:The overall success rate of oral mucosal graft repair surgery reached 97.7%(171/175). The success rate of ureteral reconstruction in the two groups were 96.4%(81/84)and 98.9%(86/87), respectively ( P=0.351), and the difference was not statistically significant. There was no significant difference for operation time, intraoperative blood loss, and mean oral mucosal length between the robotic and laparoscopic groups[(244.7±85.8) min and (222.7±83.5)min ( P=0.116), (58.9±38.6) ml and (68.4±45.5) ml ( P=0.217), (5.0±2.0) cm and (4.6±1.5) cm ( P=0.350)], respectively.Postoperative complications were reported in 23 (13.1%) patients, such as fever, urinary leakage, lymphatic leakage, infection, but only 2 (1.4%) cases patients had complications of Clavien-Dindo score ≥ Ⅲ. The two patients developed urinary stricture after surgery with failed conservative treatment, and no urinary stricture occurred following endoscopic treatment.The short-term (three months after surgery)incidence of complications in the site where the oral mucosa was taken, such as difficulty in opening mouth, pain, and swelling, was 12.0% (21/175), and there was no significant difference for oral complications between patients harvesting different length of mucosal graft. Conclusions:Ureteroplasty with oral mucosal graft is a safe, feasible and reliable technique for ureteral reconstruction. At present, minimally invasive technology is the main surgical approach for ureteroplasty, and there is no significant difference in operation time and success rate between robotic surgery and laparoscopic surgery.

Comparison of modified "double flaps" pyeloplasty and traditional pyeloplasty in the treatment of special types of hydronephrosis in children / 中华泌尿外科杂志

Objective:To compare the efficacy of modified "double flaps" pyeloplasty and traditional dismembered pyeloplasty in the treatment of special types of hydronephrosis with small pelvis and long proximal ureteral stricture in children.Methods:The data of 39 children with special types of hydronephrosis treated in Seventh Medical Center, General Hospital of PLA from June 2018 to June 2019 were retrospectively analyzed. Among them, 33 were boys and 6 were girls. The median age of the patients was 12.0(4.5, 63.5) months. Nine of them had left hydronephrosis and four children had right hydronephrosis. These patients with small pelvis existed the characteristics that the anteroposterior diameter of pelvis was smaller than 2.5 cm and these patients existed the symptom of hematuria, flank pain or recurrent urinary tract infection with the imaging revealing ureteral obstruction. The length of proximal ureteral stenosis ranged from 2.0 to 4.0 cm. Among 39 cases, 19 cases were operated with modified "double flaps" pyeloplasty, which was the modified "double flaps" pyeloplasty group. 20 cases were operated with traditional Anderson-Hynes pyeloplasty, which was traditional pyeloplasty group. The technique of modified "double flaps" pyeloplasty mainly included that the renal pelvis was cut into double flaps, the inferior flap was anastomosed with the spatulated ureter and the superior was covered, so that the length and caliber of the ureter were partial extended. The median age of two groups were 12.0 (6.0, 44.0) months and 12.0 (4.8, 62.8) months respectively, the anterior and posterior diameter of renal pelvis were (2.8±0.8)cm and (2.6±0.6)cm respectively, and split renal function were (36.7±5.1)% and (36.0±6.8)% respectively. There were no statistically significant differences in above parameters between the two groups( P>0.05). The clinical efficacy of the two groups were compared by collecting and comparing the operation related data and postoperative follow-up data. Results:The operation of 39 children in this study was successfully completed without conversion to open surgery.The operation time of "double flap" pyeloplasty group and traditional pyeloplasty group were (142.6±9.6) min and (124.5±8.6) min respectively, and the intraoperative anastomosis time were (56.1±7.2) min and (47.6±4.8) min respectively. There were significant difference in operation time and intraoperative anastomosis time between the two groups( P<0.05). Thirty-nine children were followed up normally without loss. The mean follow-up time was (27.7±2.5) months after surgery. In the "double flaps" pyeloplasty group, 2 cases suffered with fever who were diagnosed as urinary tract infection and improved after antibiotic treatment. In the traditional pyeloplasty group, 2 cases suffered with fever who were diagnosed as urinary tract infection and improved after antibiotic treatment. Two children had flank pain during follow-up to more than one year and the examination revealed that the anteroposterior diameter of the renal pelvis gradually increased. So surgery were performed again and the two children recovered. There were no significant differences in complication rate (2/19 and 4/20) and short-term surgical success rate(19/19 and 18/20) between the two groups ( P>0.05). Conclusions:The operation time and anastomosis time of the modified "double flap" technique for treating hydronephrosis are longer than those of the traditional method. But in the treatment of special types of hydronephrosis with small renal pelvis or long proximal ureteral stricture, it may have application prospects in reducing complications.

Current status and pondering of minimally-invasive surgical techniques in radical resection of hilar cholangiocarcinoma / 中华消化外科杂志

Hilar cholangiocarcinoma is one difficultly-treated biliary malignancy with poor prognosis, and radical resection offers the only hope of cure for the disease. In recent years, with development and maturation of minimally-invasive techniques, laparoscopic or robotic-assisted radical resection of hilar cholangiocarcinoma has been attempted in some major medical centers. Laparoscopic and robotic-assisted radical resection of hilar cholangiocarcinoma is technically safe and feasible at present, but there is still a lack of large number of case report and evaluation of long-term survival of patients. Based on previous literatures and combined with clinical experiences, the author elaborates on the application status of laparoscopic and robot surgical system in the radical resection of hilar cholangiocarcinoma, and discusses the key issues that should be paid attention to in carrying out this technology, such as the operator′s prerequisite requirement and patients′ selec-tion, how to ensure the radicality of surgical resection and improve the long-term outcomes.

Robot-assisted laparoscopic enucleation in the treatment of leiomyosarcoma of urinary bladder: A case report / 中南大学学报(医学版)

Leiomyosarcoma of urinary bladder (LMS-UB) is a highly malignant mesenchymal tumor, accounting for less than 0.5% of all bladder malignancies, with a predominant clinical presentation of hematuria. Here we report a case of low-grade LMS-UB. A 44-year-old male patient was admitted to the hospital with urodynia for 2 weeks. The patient's pelvis CT showed a mass on the right part of the bladder. For this reason, he was initially diagnosed with bladder cancer. We performed a robot-assisted laparoscopic enucleation of the bladder tumor and low-grade LMS-UB was diagnosed with the histopathological examination. He underwent 5 cycles of adjuvant chemotherapy after surgery. At 19months postoperative follow-up, the patient had no symptoms, recurrence, or distant metastasis. There is no report on the treatment of LMS-UB with minimally invasive enucleation worldwide. This case provides a new comprehensive treatment method of enucleation combined with adjuvant chemotherapy for early low-grade LMS-UB to reduce complications and improve patients' quality of life after surgery.

Differences in long-term continence rates between prostate cancer patients with extraprostatic vs. organ-confined disease undergoing robotic-assisted radical prostatectomy: An observational studys

ABSTRACT Objectives: Within the tertiary-case database, the authors tested for differences in long-term continence rates (≥ 12 months) between prostate cancer patients with extraprostatic vs. organ-confined disease who underwent Robotic-Assisted Radical Prostatectomy (RARP). Method: In the institutional tertiary-care database the authors identified prostate cancer patients who underwent RARP between 01/2014 and 01/2021. The cohort was divided into two groups based on tumor extension in the final RARP specimen: patients with extraprostatic (pT3/4) vs. organ-confined (pT2) disease. Additionally, the authors conducted subgroup analyses within both the extraprostatic and organ-confined disease groups to compare continence rates before and after the implementation of the new surgical technique, which included Full Functional-Length Urethra preservation (FFLU) and Neurovascular Structure-Adjacent Frozen-Section Examination (NeuroSAFE). Multivariable logistic regression models addressing long-term continence were used. Results: Overall, the authors identified 201 study patients of whom 75 (37 %) exhibited extraprostatic and 126 (63 %) organ-confined disease. There was no significant difference in long-term continence rates between patients with extraprostatic and organ-confined disease (77 vs. 83 %; p = 0.3). Following the implementation of FFLU+ NeuroSAFE, there was an overall improvement in continence from 67 % to 89 % (Δ = 22 %; p < 0.001). No difference in the magnitude of improved continence rates between extraprostatic vs. organ-confined disease was observed (Δ = 22 % vs. Δ = 20 %). In multivariable logistic regression models, no difference between extraprostatic vs. organ-confined disease in long-term continence was observed (Odds Ratio: 0.91; p = 0.85). Conclusion: In this tertiary-based institutional study, patients with extraprostatic and organ-confined prostate cancer exhibited comparable long-term continence rates.

De-Airing Maneuvers After Minimally Invasive and Robotic-Assisted Intracardiac Procedures

ABSTRACT In the setting of minimally invasive and robotic-assisted intracardiac procedures, de-airing requires further technical considerations due to limited access to the pericardial space and the subsequent difficulty of directly manipulating the heart. We summarize the technical steps for de-airing according to different cannulation strategies for minimally invasive and robotic-assisted intracardiac procedures.

Efficacy of Transversus Abdominis Plane Block in the Reduction of Pain and Opioid Requirement in Laparoscopic and Robot-assisted Hysterectomy: A Systematic Review and Meta-analysis / Eficácia do bloqueio transverso do plano abdominal na redução da dor e da necessidade de opioides em histerectomia laparoscópica e assistida por robô: Uma revisão sistemática e metanálise

Abstract Objective To summarize the available evidence of TAP Block in efficacy in laparoscopic or robotic hysterectomy. Data Sources We searched databases and gray literature for randomized controlled trials in which transversus abdominis plane (TAP) block was compared with placebo or with no treatment in patients who underwent laparoscopic or robot-assisted hysterectomy. Method of Study Selection Two researchers independently evaluated the eligibility of the selected articles. Tabulation, Integration, and Results Seven studies were selected, involving 518 patients. Early postoperative pain showed a difference in the mean mean difference (MD): - 1.17 (95% confidence interval [CI]: - 1.87-0.46) in pain scale scores (I2=68%), which was statistically significant in favor of using TAP block, but without clinical relevance; late postoperative pain: DM 0.001 (95%CI: - 0.43-0.44; I2=69%); opioid requirement: DM 0.36 (95%CI: - 0.94-1.68; I2=80%); and incidence of nausea and vomiting with a difference of 95%CI=- 0.11 (- 0.215-0.006) in favor of TAP. Conclusion With moderate strength of evidence, due to the high heterogeneity and imbalance in baseline characteristics among studies, the results indicate that TAP block should not be considered as a clinically relevant analgesic technique to improve postoperative pain in laparoscopic or robotic hysterectomy, despite statistical significance in early postoperative pain scale scores. Clinical Trial Number and Registry: PROSPERO ID - CRD42018103573.

Resumo Objetivo Resumir as evidências disponíveis sobre a eficácia do bloqueio TAP em histerectomia laparoscópica ou robótica. Fontes de Dados Pesquisamos bancos de dados e literatura cinza por ensaios clínicos randomizados nos quais o bloqueio do plano transverso do abdome (TAP na sigla em inglês) foi comparado com placebo ou com nenhum tratamento em pacientes que foram submetidos a histerectomia laparoscópica ou assistida por robô. Métodos de Seleção de Estudos Dois pesquisadores avaliaram independentemente a elegibilidade dos artigos selecionados. Tabulação, Integração e Resultados Sete estudos foram selecionados envolvendo 518 pacientes. A dor pós-operatória precoce apresentou diferença nasmédias (DM) de: -1 17 (intervalo de confiança [IC] de 95%: - 1 87-0 46) nos escores da escala de dor (I2=68%) o que foi estatisticamente significativo a favor do uso do bloqueio TAP mas sem relevância clínica; dor pós-operatória tardia: DM 0001 (IC95%: - 043-044; I2=69%); necessidade de opioides: DM0 36 (95%CI: - 0 94-168; I2=80%); e incidência de náuseas e vômitos com diferença de 95% CI=- 011 (- 0215-0006) a favor do TAP. Conclusão Com moderada força de evidência devido à alta heterogeneidade e ao desequilíbrio nas características basais entre os estudos os resultados indicam que o bloqueio do TAP não deve ser considerado como uma técnica analgésica clinicamente relevante para melhorar a dor pós-operatória em histerectomia laparoscópica ou robótica apesar da significância estatística nas pontuações da escala de dor pósoperatória inicial. Número e Registro do Ensaio Clínico: PROSPERO ID - CRD42018103573.

Clinical practice and prospect of robotic-assisted kidney transplantation / 中华泌尿外科杂志

Robotic surgery revolutionized minimally invasive surgery including kidney transplantation. Robot-assisted kidney transplantation(RAKT) has emerged as an alternative for kidney transplantation. RAKT from living donor kidney is a safe and feasible alternative to open kidney transplantation with less surgical complications without compromising renal function, graft and patient survival. The RAKT approach is promising with widespread use in the future.

Training status of operating room nurses of robotic-assisted surgery system in China: a cross-sectional survey / 中国实用护理杂志

Objective:To investigate the training status of robotic-assisted surgery nurses in hospitals with robotic-assisted surgery system in China, and to provide reference for the training and management of robotic-assisted surgery nurses.Methods:From August to December in 2021, hospitals with robotic-assisted surgery system in China were surveyed by a self-designed questionnaire distributed online.Results:The participants in the survey of 111 hospitals in 30 provinces, cities, autonomous regions and municipalities directly under the central government, nurses cooperated with robotic-assisted surgery exist the phenomenon of their own training was up to 96.40% (107/111) of hospital, 47.75% (53/111) of the hospital said the current training content also need to add other aspects of the course. Training duration of theoretical courses was 0-13 (2.86 ± 3.03) periods arranged by hospitals, and the training duration of practical courses was 1-60 (8.38 ± 9.91) d. 35.14% (39/111) of hospitals set up regular assessment after training, and the assessment cycle of them was 1-12 (4.08 ± 3.31) months. Many hospitals put forward suggestions on strengthening English training and attaching importance to team cooperation and so on.Conclusions:In our country, Robotic-assisted surgery nurses′ training has turned to that training themselves in operating rooms, the training time, form, content and other aspects have no uniform standard, strict admittance, standardization of specialist training , these are questions need to solve.

Effect of Robotic-assisted Gait Training on Motor and Walking for Children with Spastic Cerebral Palsy / 中国康复理论与实践

Objective:To investigate the effect of robotic-assisted gait training on the motor function and walking ability for children with spastic cerebral palsy. Methods:From October, 2020 to April, 2021, 34 children with spastic cerebral palsy were randomly divided into control group (n = 17) and experimental group (n = 17). The control group received conventional physical therapy 60 minutes a day, while the experimental group received physical therapy and robotic-assisted gait training, 30 minutes a day respectively. They were assessed with 10-meter walk test (10MWT), 6-minute walk distance (6MWD), Physiological Consumption Index, Gross Motor Functional Measure (D and E dimensions), center of pressure envelope area, and Functional Ambulation Categories before training, eight weeks after training, and one-month follow-up. Results:Four cases dropped out. All the indexes improved in the experimental group after training (|t| > 3.219, P < 0.05), and they were stable as follow-up (|t| < 1.565, P > 0.05), except 10MWT (|t| > 3.491, P < 0.01); while they were better than those in the control group (|t| > 2.108, P < 0.05), except 6MWD. Conclusion:Robotic-assisted gait training can promote the recovery of motor, balance and walking for children with spastic cerebral palsy based on conventional physical therapy, and remain at least one month.

Does intraoperative frozen section really predict significant positive surgical margins after robot-assisted laparoscopic prostatectomy? A retrospective study / 亚洲男科学杂志(英文版)

We investigated the relationship between positive surgical margin (PSM)-related factors and biochemical recurrence (BCR) and the ability of intraoperative frozen sections to predict significant PSM in patients with prostate cancer. The study included 271 patients who underwent robot-assisted laparoscopic prostatectomy with bilateral nerve sparing and maximal urethral preservation. Intraoperative frozen sections of the periurethra, dorsal vein, and bladder neck were analyzed. The ability of PSM-related factors to predict BCR and significant PSM was assessed by logistic regression. Of 271 patients, 108 (39.9%) had PSM and 163 (60.1%) had negative margins. Pathologic Gleason score ≥8 (18.9% vs 7.5%, P = 0.015) and T stage ≥T3a (51.9%vs 24.6%, P < 0.001) were significantly more frequent in the PSM group. Multivariate analysis showed that Gleason pattern ≥4 (vs <4; hazard ratio: 4.386; P = 0.0004) was the only significant predictor of BCR in the PSM cohort. Periurethral frozen sections had a sensitivity of 83.3% and a specificity of 84.2% in detecting PSM with Gleason pattern ≥4. Multivariate analysis showed that membranous urethra length (odds ratio [OR]: 0.79, P = 0.0376) and extracapsular extension of the apex (OR: 4.58, P = 0.0226) on magnetic resonance imaging (MRI) and positive periurethral tissue (OR: 17.85, P < 0.0001) were associated with PSM of the apex. PSM with Gleason pattern ≥4 is significantly predictive of BCR. Intraoperative frozen sections of periurethral tissue can independently predict PSM, whereas sections of the bladder neck and dorsal vein could not. Pathologic examination of these samples may help predict significant PSM in patients undergoing robot-assisted laparoscopic prostatectomy with preservation of functional outcomes.

S100B level and cognitive dysfunction after robotic-assisted laparoscopic radical prostatectomy procedures: a prospective observational study / Nível de S100B e disfunção cognitiva após prostatectomia radical laparoscópica assistida por robô: estudo observacional prospectivo

Abstract Background: The present study investigated the association between Postoperative Cognitive Dysfunction (POCD) and increased serum S100B level after Robotic-Assisted Laparoscopic Radical Prostatectomy (RALRP). Methods: The study included 82 consecutive patients who underwent RALRP. Serum S100B levels were determined preoperatively, after anesthesia induction, and at 30 minutes and 24 hours postoperatively. Cognitive function was assessed using neuropsychological testing preoperatively, and at 7 days and 3 months postoperatively. Results: Twenty four patients (29%) exhibited POCD 7 days after surgery, and 9 (11%) at 3 months after surgery. Serum S100B levels were significantly increased at postoperative 30 minutes and 24 hours in patients displaying POCD at postoperative 7 days (p = 0.0001 for both) and 3 months (p = 0.001 for both) compared to patients without POCD. Duration of anesthesia was also significantly longer in patients with POCD at 7 days and 3 months after surgery compared with patients without POCD (p = 0.012, p = 0.001, respectively), as was duration of Trendelenburg (p = 0.025, p = 0.002, respectively). Composite Z score in tests performed on day 7 were significantly correlated with duration of Trendelenburg and duration of anesthesia (p = 0.0001 for both). Conclusions: S100B increases after RALRP and this increase is associated with POCD development. Duration of Trendelenburg position and anesthesia contribute to the development of POCD. Trial Registry Number: Clinicaltrials.gov (N° NCT03018522).

Resumo Introdução: O presente estudo investigou a associação entre Disfunção Cognitiva Pós-Operatória (DCPO) e aumento do nível sérico de S100B após Prostatectomia Radical Laparoscópica Assistida por Robô (PRLAR). Métodos: O estudo incluiu 82 pacientes consecutivos submetidos à PRLAR. Os níveis séricos de S100B foram determinados: no pré-operatório, após indução anestésica, e aos 30 minutos e 24 horas do pós-operatório. A função cognitiva foi avaliada com testes neuropsicológicos no pré-operatório, no 7° dia pós-operatório (7 DPO) e aos 3 meses após a cirurgia (3 MPO). Resultados: Observamos 24 pacientes (29%) com DCPO no 7 DPO e 9 pacientes com DCPO (11%) após 3 meses da cirurgia. Quando comparados com os pacientes sem DCPO, os níveis séricos de S100B estavam significantemente aumentados aos 30 minutos e às 24 horas do pós-operatório nos pacientes que apresentaram DCPO no 7 DPO (p= 0,0001 para os dois momentos) e 3 meses após a cirurgia (p= 0,001 para os dois momentos) A duração anestésica também foi significantemente maior em pacientes com DCPO no 7 DPO e 3 MPO em comparação com pacientes sem DCPO (p= 0,012, p= 0,001, respectivamente), assim como a duração da posição de Trendelenburg (p= 0,025, p= 0,002, respectivamente). O escore Z composto nos testes realizados no 7 DPO foi significantemente correlacionado com a duração da posição de Trendelenburg e a duração da anestesia (p= 0,0001 para ambos). Conclusão: S100B aumenta após PRLAR e o aumento está associado ao desenvolvimento de DCPO. A duração anestésica e o tempo decorrido em posição de Trendelenburg contribuem para o desenvolvimento de DCPO. Número de registro do estudo: Clinicaltrials.gov (n° NCT03018522)

Implementation of enhanced recovery after surgery protocols to robotic assisted radical cystectomy with intracorporeal urinary diversion using orthotopic U-shape ileal neobladder / 中华泌尿外科杂志

Objective To discuss outcome and safety after implementation of enhanced recovery after surgery(ERAS) protocols to patients who underwent robotic assisted radical cystectomy (RARC) with intracorporeal orthotopic "U" shaped ileal neobladder creation using STAPLER technique.Methods Between October 2014 and April 2019,71 patients(59 males and 12 females)with MIBC (Muscle Invasive Bladder Cancer) who underwent RARC with intracorporeal urinary diversion using orthotopic "U" shaped ileal neobladder in Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College) were studied retrospectively.They had an average age of (65.2 ± 5.6)y and BMI of (22.18 ± 3.75) kg/m2.The median age-adjusted charlson comorbidity index (aCCI) was 4,median ASA score was 2.All patients underwent these inspections pre-RARC:chest Xray,vascular ultrasound (jugular vein included),abdominal ultrasound,CT urography,cystoscopy with biopsy or TURBT(trans-urethral resection of a bladder tumour).All patients were pathological diagnosed with MIBC,with no evidence of systemic metastasis and no history of radiotherapy,systemic chemotherapy and open abdominal surgery before RARC.All 71 patients received RARC with intracorporeal orthotopic "U" shaped ileal neobladder creation using STAPLER technique.Between October 2014 and September 2016,37 cases (29 males and 8 females) were managed without ERAS protocols perioperatively.They had an average age of (65.3 ±5.7)y and BMI of (23.66 ± 3.47)kg/m2.The median aCCI was 4,median ASA score was 2.Between October 2016 and April 2019,another group of 34 cases (30 males and 4 females) were managed with ERAS protocols including nutritional assessment,thrombosis prevention,pain assessment and management,perioperative diet management etc.They had an average age of (64.5 ± 4.3) y and BMI of (21.87 ± 4.85) kg/m2.The median aCCI was 4,median ASA score was 2.There were no statistical significance between the two groups with regard to general information.Surgical and follow-up data were collected for all patients.Results Surgeries were successful in all 71 cases with postoperative follow up for 3-51 months.In ERAS group,there were 22 cases in pT2 and 12 cases pT3 according to classification of malignant tumours:with 2 cases of incidental prostate cancer (IPCa).In non-ERAS group,pT2 in 25 cases and pT3 in 12 cases:with 1 case of IPCa.Statistical significance were observed between groups with regard to the first anal exhaust time [(20.5 ± 18.7) h vs.(29.9 ± 17.4)h,P =0.032],the first defecation time [(72.6 ±27.1)h vs.(88.7 ±35.8)h,P =0.004],length of hospital stay after surgey [(14.1 ± 3.3) d vs.(16.2 ± 4.8) d,P =0.037],numeric rating scales (NRS) Pain Score 8.0,24.0,48.0 h after surgery [(3.2 ±0.5)vs.(3.6 ±0.8),P =0.015;(1.9 ±0.3) vs.(2.2 ± 0.6),P =0.011;(1.3 ± 0.4) vs.(1.6 ± 0.7),P =0.032],respectively.There were no significance between groups with regard to operating time [(290 ± 65) min vs.(282 ± 46) min,P =O.549],intraoperative blood loss [(190.5 ± 235.6) ml vs.(221.1 ± 250.3) ml,P =0.438],transfusion rate [5.9％ (2/34) vs.8.1％ (3/37),P =0.922],readmission within 30 days after surgery [2.9％ (1/34) vs.5.4％ (2/37),P =0.940],early severe complications(within 30 days) [2.9％ (1/34) vs.2.7％ (1/37),P =0.940],late severe complications (after 30 days) [5.9％ (2/34) vs.8.1％ (3/37),P =0.922].Conclusions The implementation of ERAS protocols to patients who underwent RARC with intracorporeal orthotopic "U" shaped ileal neobladder using STAPLER technique is safe and effective.It can reduce postoperative pain and hospital stay,shorten bowel recovery time,improve early functional recovery without increasing major complications.This adoption should be encouraged.

Beneficial effect of fluid warming in elderly patients with bladder cancer undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy

OBJECTIVES: The enhanced recovery after surgery (ERAS) protocol recommends prevention of intraoperative hypothermia. However, the beneficial effect of maintaining normothermia after radical cystectomy has not been evaluated. This study aimed to investigate the efficacy of fluid warming nursing in elderly patients undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy. METHODS: A total of 108 patients with bladder cancer scheduled to undergo DaVinci robotic-assisted laparoscopic radical cystectomy were recruited and randomly divided into the control group (n=55), which received a warming blanket (43°C) during the intraoperative period and the warming group (n=53), in which all intraoperative fluids were administered via a fluid warmer (41°C). The surgical data, body temperature, coagulation function indexes, and postoperative complications were compared between the two groups. RESULTS: Compared to the control group, the warming group had significantly less intraoperative transfusion (p=0.028) and shorter hospitalization days (p<0.05). During the entire intraoperative period (from 1 to 6h), body temperature was significantly higher in the warming group than in the control group. There were significant differences in preoperative fibrinogen level, white blood cell count, total bilirubin level, intraoperative lactose level, postoperative thrombin time (TT), and platelet count between the control and warming groups. Multivariate linear regression analysis demonstrated that TT was the only significant factor, suggesting that the warming group had a lower TT than the control group. CONCLUSION: Fluid warming nursing can effectively reduce transfusion requirement and hospitalization days, maintain intraoperative normothermia, and promote postoperative coagulation function in elderly patients undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy.

The initial experience of robotic-assisted laparoscopic pyeloplasty in the treatment of infant with ureteropelvic junction obstruction / 中华泌尿外科杂志

Objective To investigate the feasibility and safety of robotic-assisted laparoscopic pyeloplasty (RALP) in infant ureteropelvic junction obstruction.Methods Of 31 infants who underwent RALP between March 2017 and August 2017 were reviewed,including 25 boys and 6 girls.22 infants were found that the hydronephrosis was in the left kidney and 9 in the right kidney.The average age of the infants was (3.5 ± 0.7) months,ranged from 8 days to 6 months,including 7 infants less than 2 months.The average weight of the infants was (6.7 ± 1.2) kg,with a minimum weight of 3.3 kg.The diagnosis and outcomes of ureteropelvic junction obstruction (UPJO) were reviewed on clinical and imaging data.The ultrasound showed that the mean anteroposterior diameter of hydronephrotic kidney was (4.01 ±0.56)cm.The split renal function was (37.1 ± 3.2) ％ in infants who were more than 2 months.Patients with proximal defect were positioned in the lateral flank position with 50°-70° inclination and as close as possible to the edge of operating table.The trocars of robotic lens and No.1 robotic arm were placed on the middle of the umbilicus and the Pfannenstiel line respectively,and the trocar of No.2 robotic arm was placed on the supraumbilical symmetry point of the trocar No.1 robotic arm,and the auxiliary trocar was placed on the Pfannenstiel line outside the 3-4 cm of healthy side of the trocar of No.1 robotic arm.During operation,the ureteropelvic junction was dissected and tailored.Then the ureter was open longitudinally at the posterior lateral side and was anastomosed at the lowest part the renal pelvis.We assessed preoperative clinical data and outcomes,and analyzed the transition experience.Data are expressed as medians for continuous variables.Results All operations were successful with no serious intraoperative complication and traditional laparoscopic or open surgical conversion.The average operative time was 108 min,the average intraoperative blood loss was 9.5 ml.The average drain removal was 1.2 days,the average start oral of feeding was 3.2 hours days and the average postoperative hospital stay was 6.2 days.Postoperative pathological results showed smooth muscle hyperplasia,hypertrophy and fibrous tissue in the urothelium,accompanied by chronic inflammation of urothelial mucosa.Patients with Clavien Ⅰ and Ⅱ complications 22.6％ (7/31) postoperatively were managed conservatively.Among them,there were 1 cases of flank pain,1 cases of hematuria,2 cases of urinary leakage,and 3 cases of urinary tract infection.Patients' symptoms disappeared by conservative treatment.No patient suffered Clavien Ⅲ and Ⅳ complication postoperatively.The renal pelvis anteroposterior diameter was 1.58 cm at three months postoperatively,which was significantly smaller than that of peroperation (P ＜ 0.05).A diuretic T1/2 showed the improvement of split renal function without urinary obstruction in all patients at three months postoperatively.The postoperative split renal function was (39.2 ± 3.5) ％,which was slightly higher than that of preoperation (P ＞ 0.05).Conclusions Severe hydronephrosis in neonates can be acted as an indication for exploratory surgery when the surgeon's ability,anesthesia,monitoring and management conditions are available.Robotic-assisted laparoscopic pyeloplasty is a safe and feasible option for the treatment of UPJO in infant with less trauma,rapid recovery and good cosmetic result.We suggest that RALP is potentially a recommended feasible treatment option for infant with UPJO.

Curative effects of anatomic reconstruction of periurethral structure in robotic assisted laparoscopic radical prostatectomy / 中华泌尿外科杂志

Objective To investigate the outcome of patients underwent anatomic periurethral reconstruction during robotic assisted laparoscopic radical prostatectomy (RARP).Methods During August 2016 to May 2018,anatomic periurethral reconstruction was performed during RARP in 58 consecutive patients.The control group consists of another 50 patients had no anatomic periurethral reconstruction procedure during RARP.Perioperative data of these patients were collected retrospectively,including operation time,anastomosis timeintraoperative blood loss,duration of indwelling catheter,length of hospital stay,complications,postoperative pathology,and continence outcome at 1,3,6,12 months after surgery.Results All cases were successfully performed without conversion to open or laparoscopic surgery.There were no major intraoperative or postoperative complications.Operative time and anastomosis time was (145.3 ± 12.3)mins and (31.6 ± 8.2)mins in reconstruction group comparing to (122.4 ± 11.4)mins and (21.2 ± 4.4) in control group (both P ＜ 0.05).Duration of indwelling catheter was (7.0 ± 0.5) days in reconstruction group and (11.0 ± 0.6) days in control group (P ＜ 0.05).In reconstruction group,estimated blood loss was (108.1 ± 8.3) ml,duration of drainage tube was (3.0 ± 1.2) d,postoperative hospital stay was (8.0 ± 1.1) d,failure of leak test in 1 case,and postoperative complications in 4 cases (6.9％),comparing to (103.3 ± 10.4) ml,(4.0 ± 1.6) d,(10.0 ± 1.5) d,3 cases and 4 cases (8.0％) in control group with no significant difference (all P ＞ 0.05).Postoperative pathology confirmed 53 T2a-T2b diseases and 5 pT2c diseases in reconstruction group,in comparison with 46 T2a-T2b and 4 pT2c diseases in nonreconstruction group (P ＞ 0.05).There were 19 and 15 cases with a final Gleason score of 6,30 and 27 cases with Gleason 7,9 and 10 cases with Gleason 8,in reconstruction group and non-reconstruction group respectively(all P ＞ 0.05).There was no significant difference between the two groups regarding incidence of positive surgical margins (3 in reconstruction group and 2 in control group,P ＞ 0.05).The percentage of patients maintain continence in reconstruction group and non-reconstruction group:at 1 month [84.5 ％ (49/58) and 70.0％ (35/50)],at 3 months [89.7％ (52/58) and 78.0％ (39/50)],at 6 months [91.3 ％ (53/58)and 86.0％ (43/50)] and 1 year after surgery [100.0％ (58/58) and 96.0％ (48/50)].Reconstruction group showed better continence outcome at 1 and 3 month (P ＜ 0.05),with no statistical differences at 6 month and 1 year.The IPSS 1 year after surgery was 10.4 ± 1.6 and 12.1 ± 1.3,with anastomotic stricture in 0 and 2(4％) patients in reconstruction group and control group,respectively (both P ＞ 0.05).Conclusion Anatomic reconstruction of periurethral structure during RARP is safe and feasible with reduced duration of indwelling catheter and better continence outcome.

Extraperitoneal approach robotic-assisted urethra-sparing simple prostatectomy for large-gland benign prostatic hyperplasia: initial experience / 中华泌尿外科杂志

Objective@#To report our initial experience with extraperitoneal approach Robotic-Assisted Urethra-sparing simple prostatectomy(US-RASP)on large-gland (>100 ml) benign prostatic hyperplasia(BPH).@*Methods@#From August 2015 to April 2018, 32 patients with large volume prostate underwent US-RASP performed by single surgical team were retrospectively reviewed. The patient's median age was 73 (range 59-80) years, and median BMI was 24.9 (19.3-34.8 ) kg/m2, The estimated prostate volume(V), postvoid residual volume(PV) by transrectal ultrasonography and PSA were 152.0(119.0-223.1)ml, 145(0-280)ml and 13.7(5.2-27.3)ng/ml, respectively. Four of 32 patients underwent preoperative urinary catheterization. The perioperative functional parameters including international prostate symptom score (IPSS) questionnaire, maximum flow rate (Qmax), maximum voided volume(Vmax), quality of life questionnaires (QOL) and International Index of erectile function-erectile function (IIEF-EF) were 27(23-33), 5.9 (2.5-7.8) ml/s, 110 (80-210)ml, 5(3-6), and 27(26-29), respectively. Functional parameters including IPSS, QOL, Qmax, Vmax, PV and IIEF-EF were compared and analyzed at 3 and 12 months postoperatively during the following-up.@*Results@#The US-RASP was completed in all 32 patients and no open conversion. Median operation time was 180 (115-240) min, the estimated blood loss was 300(range 100 to 400)ml, Hemoglobin loss was 17(5-38)g/L. The median Foley catheterization time was 7 (5-12) days and drainage was removed after a median of 5 (4-7) days with median hospital stay of 8(6-14)days. Median specimen weight on pathological examination was 107.7 (79.8-147.4)g with median of 64.2% (49.4%-86.2%) resection ratio. At 3-mo follow-up, median IPSS score, Qmax, Vmax, PV and QOL were 6(4-18), 17.3 (13.8-21.1)ml/s, 167(140-310)ml, 50(0-61)ml, 1(0-3) , respectively. At 12-mo follow-up, median IPSS score, Qmax, Vmax, PV and QOL were 4(1-9), 20.1 (17.9-24.1)ml/s, 205(176-305)ml, 24(0-35)ml and 1(0-2) , respectively. All patients showed great improvement of IPSS, Qmax, Vmax, PV and QOL after median 17 (12-44) months follow-up compared with preoperative parameters (P<0.05). Erectile function was not impaired in 17 patients who have normal erectile function pre-operatively and 14 cases (82.4%) preserved satisfactory anterograde ejaculation. No significant complication occurred during the procedure. No patient developed permanent urinary incontinence.@*Conclusions@#US-RASP is a safe and effective treatment option for selected patients with large-gland obstructive BPH(>100 ml). Our data showed significant improvement in voiding function and maintaining satisfactory anterograde ejaculation following urethral-sparing technique. It may be a new alternative method in the future for large-volume symptomatic BPH.

Current surgical practices of robotic-assisted tissue repair and reconstruction / 中华创伤杂志(英文版)

This paper systematically reviewed and analyzed the recent publications of robotic-assisted surgeries in the field of tissue repair and reconstruction. Surgical robots can elevate skin flap more accurately and shorten the time of tissue harvest. In addition, robotic-assisted surgery has the advantage of minimal tissue trauma and thus forms minimal scar. The utilization of surgical robots reduces the occurrence of complications after oral radical tumor resection while achieving cosmetic sutures. Robotic-assisted radical mastectomy could radically remove invasive breast cancer lesions and achieve breast reconstruction in the first stage through the small incisions in the operation areas. Surgical robots enable precise microvascular anastomosis and reduce tissue edema in the surgical field. Robotic-assisted technology can help appropriately locate the target tissues at different angles during sinus and skull base surgeries and accurately place tissues during urethroplasty. The robotic-assisted technology provides a new platform for surgical innovation in the field of tissue repair and reconstruction. However, the uncertainty in the survival rate after tumor radical surgery, the increase of operating time, and the high costs are barriers for its clinical application in tissue repair and reconstructive surgery. Nevertheless, robotic-assisted technology has already demonstrated an impact on the field of tissue repair and reconstruction in a meaningful way.