The effect of nerve-sparing robot-assisted radical cystoprostatectomy on erectile function in a preoperatively potent population.

OBJECTIVE: To evaluate the effects on the potency of a bilateral cavernosal nerve-sparing approach to robot-assisted radical cystectomy (RARC) in a preoperatively potent population. PATIENTS AND METHODS: We conducted a retrospective review of 254 patients who underwent RARC between 2003 and 2012 at our single institution. We identified 33 men who were younger than 65 years and had evidence of preoperative erections on chart review. Twenty-nine of them underwent a bilateral nerve-sparing procedure, with 28 (97%) having concomitant creation of a continent urinary diversion. RESULTS: Median follow-up was 32.9 months. Postoperatively, 13 (45%) patients had documented erections sufficient for penetration with or without the use of phosphodiesterase 5 inhibitors. Additional 6 (21%) were potent with intracavernosal injections (ICI), and the remaining 10 (34%) failed ICI usage, had on-going medical issues, or lost interest in sexual activity. With univariate analysis, no significant difference was found between those who recovered erections and those who did not on a wide range of demographic, operative, and perioperative factors, including age, comorbidities, operative time, or pathologic stage. Despite neurovascular bundle preservation, there was no local cancer recurrence and no positive soft tissue margins. CONCLUSION: A cavernosal nerve-sparing robot-assisted approach to radical cystectomy allows for recovery of potency without sacrificing oncologic outcomes even with higher risk disease as compared to historical open or laparoscopic series. Further studies are required to help elucidate why some men have better recovery in this setting than others.

Robot-assisted laparoscopic ureteral reimplantation: a single surgeon comparison to open surgery.

OBJECTIVE: The aim was to report a single surgeon's experience comparing open and robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) to treat vesicoureteral reflux (VUR). SUBJECTS AND METHODS: We retrospectively reviewed the outcomes of RALUR and open extravesical ureteral reimplantations consecutively performed by a single surgeon between January 2008 and December 2010 using the da Vinci(®) Surgical System. Both groups of patients were subjected to identical pre- and postoperative care protocols. RESULTS: During the defined study interval, 20 open and 20 RALUR procedures were completed by a single surgeon at our institution. Gender and VUR grade were similar in both cohorts. Operative times were longer in the RALUR group, but postoperative opioid use (morphine equivalents) was significantly lower in the RALUR group (RALUR: 0.14 mg/kg, open: 0.25 mg/kg, p = 0.021). There was no significant difference in estimated blood loss (EBL) or length of hospitalization (LOH). The overall rate of surgical complications was similar; however, the complications in the open group tended to be less severe than those occurring in the RALUR group. On follow-up, after a median of 52 months for open surgery and 39 months for RALUR, two children had developed a febrile urinary tract infection in both groups, of which one in the open group had persistent VUR. CONCLUSION: This single-surgeon experience of open and initial experience with RALUR performed with the same surgical technique on consecutive cohorts with identical post-surgical care protocol allows a comparative analysis of outcomes for a surgeon transitioning to RALUR. The RALUR reduces postoperative analgesic requirements while yielding similar clinical outcomes as the open technique.

Robot-assisted laparoscopic ipsilateral ureteroureterostomy for ectopic ureters in children: description of technique.

PURPOSE: We report our experience and present our technique with the robot-assisted laparoscopic ipsilateral ureteroureterostomy (IUU) in the management of ureteral duplication with ectopia in children. PATIENTS AND METHODS: We reviewed our institutional experience for all patients who underwent a robot-assisted laparoscopic IUU at the University of Minnesota Amplatz Children's Hospital between December 2010 and October 2011. An intraoperative, three-port technique was used after a ureteral stent was placed into the ipsilateral lower pole. Demographic information, diagnosis, operative time, hospital course, complications, and follow-up were all evaluated. RESULTS: Our series included four female patients and one male patient with a mean age of 61 months (6 to 182 mos). All five had a diagnosis of upper pole ectopic ureters, one of which was associated with an ureterocele. Mean total operative time was 225 minutes (181 to 253 min), and mean hospital stay was 1.2 days (1-2 days). There were no intraoperative complications. In follow-up, at the time of ureteral stent removal, pyelonephritis developed in one patient, but all patients had resolution of their presenting symptoms including urinary tract infections and incontinence. A significant reduction in upper pole hydronephrosis was seen in all patients. CONCLUSIONS: Our experience indicates that robot-assisted laparoscopic IUU is safe and effective in the management of ureteral duplication anomalies in children.

A dual-channel flexible ureteroscope: evaluation of deflection, flow, illumination, and optics.

BACKGROUND AND PURPOSE: Despite the evolution and progressive improvements of ureteroscopes, problems related to visibility and maneuverability can still hinder the goals of surgical intervention. We evaluate the attributes of a dual-channel flexible ureteroscope compared with a single-channel device and discuss the implications for expanded techniques afforded by this new technology. MATERIALS AND METHODS: In vitro measurements of active deflection, irrigant flow through the working channel, luminescence, and optical resolution were performed between the single-channel Wolf Viper and the dual-channel Wolf Cobra ureteroscopes. Characteristics were obtained with the working channels both empty and with combinations of a 200 µ holmium aser fiber, 3.0F biopsy forceps, and 1.5F, 2.4F, and 2.8F nitinol basket. Luminescence from each scope was measured using a commercial luminometer. Three blinded physicians rated the optical resolution captured electronically using a standard test image. RESULTS: The single-channel scope has improved upward deflection both empty and with all but the largest single tools, with an improved range of 4 to 15 degrees. The dual-channel scope has superior downward deflection across all comparisons (average increase of 24.5 degrees) and superior upward deflection with large or multiple instruments in the working channel. Baseline flows through each individual-channel of the dual-channel scope were slower than the larger single-channel ureteroscope. Because flow can be provided through a dedicated port in the dual-channel configuration, however, overall flow, depending on instrumentation, can be up to 37 times faster than the single-channel (range 1.5-37×). Optical resolution and luminescence are comparable between the two scopes. CONCLUSION: The dual-channel flexible ureteroscope provides similar deflection characteristics to the current single-channel scope. Deflection and flow characteristics are superior, however, when larger or multiple simultaneous instruments are used in the working channel. These benefits may facilitate the development and implementation of novel endoscopic procedures.

Effects of video digitization in pubic arch interference assessment for prostate brachytherapy.

Recently, it has been shown that prior to surgery a transrectal ultrasound (TRUS) study of the prostate and pubic arch can effectively determine pubic arch interference (PAI), a major stumbling block for the prostate brachytherapy (radioactive seed implantation) procedure. This PAI determination is currently being done with digital images taken directly from an ultrasound (US) machine. However, 70-75% of US machines used in prostate brachytherapy do not have a method to save or transfer digital image data for external use. To allow PAI assessment regardless of US platform and to keep costs to a minimum, we need to digitize the images from the US video output when there is no direct digital transfer capability. D/A and A/D conversions can introduce quantization error and other noises in these digitized images. The purpose of this work is to assess the image degradation caused by digitization and quantitatively evaluate whether after digitization it is still possible to accurately assess PAI. We used a PAI assessment algorithm (developed in previous research by our group) to predict the location of the pubic arch on both digital images and those captured after digitization. These predicted arch locations were compared to the "true" position of the pubic arch as established during surgery. Despite apparent image degradation due to the D/A and A/D conversions, we found no statistically significant difference between the accuracy of the predicted arch locations from the digitized images and those from the digital images. By demonstrating equally accurate determination of pubic arch locations using digital and digitized images, we conclude that TRUS-based PAI assessment can be easily and inexpensively performed in clinics where it is needed.