Robotic-assisted aortic surgery with and without minilaparotomy for complicated occlusive disease and aneurysm.

OBJECTIVE: Published reports of robotic-assisted aortic surgery involve a combination of laparoscopy for aortic dissection and a robotic system for vascular reconstruction. The objective of this study is to determine the feasibility and advantage of a total robotic-assisted aortic dissection and vascular reconstruction vs robotic-assisted aortic procedures for aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA). METHODS: From February 2006 to August 2010, 21 patients were selected for robotic-assisted aortic procedures: aortobifemoral bypass in 12, AAA repair in 6, iliac aneurysm repair in 1, and ligation of type II endoleak after endovascular aneurysm repair in 2. Inclusion criteria included AAA >5 cm, iliac aneurysm >3 cm, and AIOD TransAtlantic InterSociety Classification (TASC) C or D lesions. The da Vinci S Surgical System (Intuitive Surgical Inc, Sunnyvale, Calif) was used for the abdominal aortic dissection in all cases and for the aortic anastomosis in three cases. RESULTS: The 21 patients (6 women, 15 men) were an average age of 65.7 years (range, 44-86 years), had a body mass index (BMI) of 27.23 kg/m(2), and 90.4% were American Society of Anesthesiologists (ASA) class 3 or 4. Robotic dissection of the abdominal aorta was successful in 20 patients (95.2%). One patient required full conversion to open AAA repair due to trocar injury. Of the remaining 20 patients, the average robotic dissection time of the infrarenal aorta was 113.1 minutes, and the average aortic clamp time was 86 minutes. The procedure in 15 patients was performed with a minilaparotomy using an average abdominal incision of 13 cm to implant the Dacron or polytetrafluoroethylene graft. Five patients underwent a total robotic-assisted procedure with robotic aortic reconstruction or ligation of a type II endoleak. The 30-day survival rate was 100%. Median length of stay was 7.5 days. All grafts were patent at a median follow-up of 32.0 months. CONCLUSIONS: For aortic procedures completed total robotically without an abdominal incision, the estimated blood loss was significantly less than in robotic-assisted procedures with a minilaparotomy. In these selected patients, robotic-assisted technology may be part of the armamentarium for the vascular surgeon as another less invasive method for the treatment of complicated occlusive disease or aneurysm.

Successful total robotic-assisted aortobifemoral bypass for treatment of complicated aortoiliac occlusive disease.

Laparoscopic aortobifemoral bypass (AFB) for aortoiliac occlusive disease (AIOD) is a durable, minimally invasive procedure with comparable long-term outcomes to conventional open AFB. However, laparoscopic AFB requires advance training in laparoscopy with prolong learning curve to accomplish infrarenal aortic dissection and vascular reconstruction to minimize aortic clamp time and leg ischemia time. We describe another minimally invasive technique of total robotic-assisted AFB for extensive, complicated AIOD in 3 patients who are not endovascular candidate or have failed endoluminal approach previously.

Role of PSA velocity in predicting pathologic upgrade for Gleason 6 prostate cancer.

BACKGROUND: Pathologic upgrading to Gleason 7 or higher on radical prostatectomy (RP) specimens occurs in many patients with Gleason 6 prostate cancer on preoperative biopsy. We evaluated whether biopsy characteristics and preoperative factors, including preoperative PSA velocity (PSAV), are predictive of pathologic upgrading. MATERIALS AND METHODS: We identified 235 consecutive Gleason 6 prostate cancer patients who underwent biopsies at our institution, had multiple pre-biopsy PSA values, and eventually underwent RP. Preoperative biopsy, clinical characteristics, and PSAV were analyzed to determine the risk of pathologic upgrading or extracapsular extension. These clinical factors were evaluated for association with biochemical recurrence following RP. RESULTS: Overall, 48% of patients were upgraded to Gleason grade 7 or higher following RP. Median PSAV was 0.61 ng/mL/y, and PSAV was similar between upgraded and non-upgraded patients (1.01 vs. 0.78, P = 0.1). PSA velocity level was not associated with extracapsular disease (P = 0.4). PSA velocity > 1 was associated with biochemical recurrence (HR 3.23, P = 0.01) but this was not statistically significant in a multivariable model. Increasing PSA density (HR 2.18, P < 0.001), bilateral cores positive (HR 1.89, P < 0.05), and any biopsy core involvement > 50% (HR 2.52, P < 0.05) were most associated with pathologic upgrading. On multivariate analysis, only bilateral cancer detection at biopsy (HR 1.90, P < 0.05) significantly predicted upgrading. CONCLUSIONS: PSAV has a limited role in predicting Gleason 6 upgrading. Patients with bilateral cancer detected on transrectal biopsy should be encouraged to have radical local therapy due to high risk of harboring more aggressive disease.

Robot-assisted management of congenital renal abnormalities in adult patients.

INTRODUCTION: Congenital anomalies of the genitourinary tract are usually diagnosed and corrected in childhood. Robot-assisted management of congenital urologic abnormalities in adult patients has not been described previously. We present a series of patients with congenital renal abnormalities diagnosed in adulthood and managed using a robotic approach. METHODS: Four patients at our institution were identified with congenital renal abnormalities diagnosed in adulthood. One had a duplicated collecting system with hydronephrosis of a thinned out upper pole moiety and underwent heminephroureterectomy. A second had right hydronephrosis, complete atrophy of the right renal cortex, and a dilated tortuous ureter with obstructing ureterocele and underwent simple nephrectomy. A third patient had a duplicated system with distal ureteral reflux and an ureterocele and underwent ureteroureterostomy and distal ureterectomy. The fourth had a duplicated collecting system with ureterovaginal fistula of the upper pole moiety. Perioperative variables were collected including operative time, estimated blood loss, length of hospital stay, and change in estimated creatinine clearance. RESULTS: Mean age was 35 years (range 16-54), mean body mass index was 30.9 kg/m(2) (21.8-42.5), and mean baseline estimated creatinine clearance was 147.7 mL/minutes (107.7-214.6). Mean operative time was 258 minutes (151-374) and mean estimated blood loss was 44 mL (25-50). Postoperative estimated creatinine clearance was 133.1 mL/minutes (115.9-160.9), which was not statistically different from preoperative values (p = 0.608). All patients were discharged by postoperative day 2. There were no perioperative complications. CONCLUSIONS: Robot-assisted management of congenital renal abnormalities is a feasible and efficacious treatment modality in adult patients with low morbidity and good outcomes.

Men presenting for radical prostatectomy on preoperative statin therapy have reduced serum prostate specific antigen.

PURPOSE: Studies have suggested that statin (3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors) medication use may decrease prostate specific antigen in healthy men. We determined the effect of preoperative statin use on total preoperative prostate specific antigen and the risk of biochemical recurrence in patients with prostate cancer presenting for radical prostatectomy. MATERIALS AND METHODS: A retrospective review of 3,828 patients undergoing radical prostatectomy from January 2001 to July 2008 at our institution identified 1,031 on statin medications. We compared these 1,031 patients to the remaining 2,797 not on statins preoperatively. We evaluated differences in prostate specific antigen overall, and when patients were stratified by age specific groups, body mass index and Gleason grades on final pathology. We also investigated differences in biochemical recurrence rates. RESULTS: Overall median serum prostate specific antigen was lower in patients on preoperative statins (5.0 vs 5.2 ng/ml, p = 0.002). Median prostate specific antigen was lower in men on statins with Gleason grades 7 or 8/9 disease (p <0.05). Using a multivariate logistic regression model statin therapy was associated with a 4.7% decrease in prostate specific antigen (p <0.001). Statin therapy was not associated with an overall decreased risk of biochemical recurrence (p = 0.73) at a mean followup of 26 months. CONCLUSIONS: In this cohort of men presenting for radical prostatectomy serum prostate specific antigen is significantly lower in patients with prostate cancer on preoperative statins compared to those not taking these medications. Prospective studies are required to evaluate if this decrease in prostate specific antigen leads to later detection of prostate cancer or variations in oncological outcomes.

Retroperitoneal robotic renal surgery: technique and early results.

We describe a robotic retroperitoneal approach to renal surgery, optimized in porcine and cadaveric models, and applied to human patients. A retroperitoneal approach for robotic kidney surgery was developed in nonsurvival porcine and a fresh cadaver models, and then utilized in ten patients (three partial nephrectomy, three radical nephrectomy, two simple nephrectomy, one pyeloplasty, one cryoablation). Retroperitoneal access was successfully achieved for robotic renal procedures in six pigs and a human cadaver. Ten human patients (mean age 56 years, range 36-72 years) then underwent a successful retroperitoneal approach for robotic renal surgery. Mean console time was 166 (120-300) min. Mean blood loss was 82 (50-100) ml and average hospital stay was 2.6 (1-5) days. Pathology demonstrated clear cell renal cell carcinoma (four), papillary renal cell carcinoma (two), and xanthogranulomatous pyelonephritis (two). One patient with xanthogranulomatous pyelonephritis required open conversion for failure to progress due to dense adhesions. A retroperitoneal approach is a safe and feasible alternative to a transperitoneal approach for robotic renal surgery, including radical nephrectomy, partial nephrectomy, pyeloplasty, and cryoablation.

Radical prostatectomy: a single surgeon comparison of retropubic, perineal, and robotic approaches.

OBJECTIVE: To compare perioperative, functional and oncological outcomes of a single surgeon's experience with retropubic (RRP), perineal (RPP), and robotic assisted (RARP) radical prostatectomy. METHODS: Results from 150 radical prostatectomies performed by a single surgeon were compared. The groups consisted of the last 50 consecutive RRP (group 1) and RPP patients (group 2) and his first 50 RARP patients (group 3). He had significant experience in RRP and RPP and extensive training prior to performing RARP. The data was obtained from record review and patient survey. Patient demographics, operative parameters, pathological characteristics, complications, and functional outcomes were compared between groups. RESULTS: The groups were comparable with respect to patient demographics. Hospital stay, blood loss, and transfusion requirements were significantly better in the robotic group. Complications were least in the robotic group. Urinary continence (one pad or less) at 12 months was 96% in RRP, 96% in RPP, and 96% in RARP group. Positive surgical margins in organ confined disease were significantly lower for RARP although overall positive margins were similar. Potency data was still maturing and was not included in this analysis. CONCLUSIONS: There were no major differences in outcomes between the RRP and RPP groups. The RARP group had equal or better perioperative outcomes in all analyzed categories with the least complications. Urinary function outcomes were excellent in all groups. Prior open experience and extensive training facilitate encouraging outcomes for robotic prostatectomy even in a surgeon's initial series of patients.

Perioperative complications of robotic radical prostatectomy after the learning curve.

PURPOSE: We assessed the incidence of and analyzed factors that contributed to perioperative complications in patients undergoing robotic radical prostatectomy, that is Vattikuti Institute prostatectomy (VIP), at our institution. MATERIALS AND METHODS: We recorded operative and postoperative data on 300 consecutive patients who underwent VIP at our institution during a 1-year period. All operations were performed by 1 of 2 surgeons (MM or JOP). We reviewed the complications seen in these patients. RESULTS: There was no operative mortality and no case was converted to open surgery. A total of 269 (89.7%) patients were considered to have an ideal postoperative course, ie they were discharged home within 48 hours with no unscheduled office visits or complications. There were 14 unscheduled postoperative visits (4.7%) for transient urinary retention after early catheter removal (13) or hematuria (1). There were 17 complications, of which 16 (5.3%) were related to surgery and 1 was related to anesthesia. A total of 11 complications (3.7%) were minor (grade I) and 5 (1.7%) were major (grade II). Of them 3 (1%) patients required reoperation. There were no grade III or IV complications. CONCLUSIONS: In our hands VIP is a safe operation with an overall complication rate of 5.3%, a major complication rate of less than 2% and a surgical re-intervention rate of 1%.