Lower extremity neuropathies after robot-assisted laparoscopic prostatectomy on a split-leg table.

BACKGROUND AND PURPOSE: Lower extremity neuropathies from prolonged lithotomy positioning have been well documented. When we initiated our robot-assisted laparoscopic prostatectomy (RALP) program in December 2002, we chose to use the split-leg table that allows patient support in a more anatomic position, hypothesizing that this would reduce risk of neurologic compression injuries. We report our incidence of lower extremity neuropathies associated with RALP using split-leg positioning and review patient and surgical variables associated with this complication. PATIENTS AND METHODS: We retrospectively reviewed records of 377 patients who underwent RALP using a split-leg table. Patient data including height, weight, body mass index, age, and smoking status; surgical variables such as surgeon operative experience and intraoperative times were also assessed. Intraoperative time was defined as anesthesia induction to anesthesia emergence to more accurately measure total time patients spent in the split-leg position. RESULTS: Of 377 patients, lower extremity neuropathies developed in 5 (1.3%) in the immediate postoperative period. Of all variables examined, only increased intraoperative time was identified as a potential risk factor for the development of this complication (496.2 ± 34.8 min vs 366.3 ± 96.1 min, P<0.001). Overall mean operative time for all patients was 368.0 ± 96.6 minutes. Three of the five patients had symptoms suggestive of a femoral mononeuropathy. CONCLUSIONS: Intraoperative time as defined in our study is a significant risk factor for development of postoperative neuropathy. We also found that split-leg positioning appears to put the femoral nerve at risk for injury, instead of the common peroneal nerve as has been previously reported from prolonged lithotomy positioning.

Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.

BACKGROUND AND PURPOSE: Surgery is a high-stakes "performance." Yet, unlike athletes or musicians, surgeons do not engage in routine "warm-up" exercises before "performing" in the operating room. We study the impact of a preoperative warm-up exercise routine (POWER) on surgeon performance during laparoscopic surgery. MATERIALS AND METHODS: Serving as their own controls, each subject performed two pairs of laparoscopic cases, each pair consisting of one case with POWER (+POWER) and one without (-POWER). Subjects were randomly assigned to +POWER or -POWER for the initial case of each pairing, and all cases were performed ≥ 1 week apart. POWER consisted of completing an electrocautery skill task on a virtual reality simulator and 15 minutes of laparoscopic suturing and knot tying in a pelvic box trainer. For each case, cognitive, psychomotor, and technical performance data were collected during two different tasks: mobilization of the colon (MC) and intracorporeal suturing and knot tying (iSKT). Statistical analysis was performed using SYSTAT v11.0. RESULTS: A total of 28 study cases (14+POWER, 14-POWER) were performed by seven different subjects. Cognitive and psychomotor performance (attention, distraction, workload, spatial reasoning, movement smoothness, posture stability) were found to be significantly better in the +POWER group (P ≤ 0.05) and technical performance, as scored by two blinded laparoscopic experts, was found to be better in the +POWER group for MC (P=0.04) but not iSKT (P=0.92). Technical scores demonstrated excellent reliability using our assessment tool (Cronbach ∝=0.88). Subject performance during POWER was also found to correlate with intraoperative performance scores. CONCLUSIONS: Urologic trainees who perform a POWER approximately 1 hour before laparoscopic renal surgery demonstrate improved cognitive, psychomotor, and technical performance.

Current minimally invasive practice patterns among postgraduate urologists.

PURPOSE: To determine laparoscopic and robotic surgical practice patterns among current postgraduate urologists. MATERIALS AND METHODS: There were 9,095 electronic surveys sent to practicing urologists with e-mail addresses registered with the American Urological Association. RESULTS: Responses were received from 864 (9.5%) urologists; 84% report that laparoscopic or robotic procedures are performed in their practice. The highest training obtained by the primary laparoscopist was fellowship (31%), residency (23%), or 2- to 3-day courses (22%). Eighty-six percent report performance of laparoscopic nephrectomy in their practice, and 71% consider it the standard of care. Sixty-six percent of practices have access to at least one robotic unit, and 9% plan on purchasing one within a year. Attitudes toward robotics are favorable, with 80% indicating that it will increase in volume and potential procedures. Thirty-one percent state that robot-assisted prostatectomy is standard of care, while 50% believe this procedure looks promising. Respondents think that optimal training in minimally invasive techniques is fellowships (23%), minifellowships (23%), or hands-on courses (23%). Twenty-nine percent think that they were trained adequately in laparoscopy and robotics from residency, and 62% believe residents should be able to perform most laparoscopic procedures on completion of residency. CONCLUSIONS: The practice and availability of laparoscopic and robotic procedures have increased since previous evaluations. Opinions regarding these techniques are favorable and optimistic. As the field of urology continues to see a growing demand for minimally invasive procedures, training of postgraduate urologists and residents remains essential.

Successful outcomes of older donors in laparoscopic donor nephrectomy.

BACKGROUND AND PURPOSE: Healthy older living donors (> 50 years) are helping meet increasing demands for kidney transplantation. Live donor grafts perform better than cadaveric donor grafts; however, concern surrounds the expected nephron loss of the donors as well as the relative safety to the donor. We examined the effect age had on living laparoscopic donor and recipient outcomes at a single institution. PATIENTS AND METHODS: We retrospectively reviewed records of 101 patients who underwent laparoscopic donor nephrectomy (LDN) from October 2001 to December 2005. Twenty-nine (29%) who were aged 50 years or older, denoted as the "older" group, were compared with the remaining 72 (71%) donors who were younger than 50 years and served as controls. Perioperative and follow-up data were analyzed for both groups. RESULTS: The mean age at the time of donation was 36.1 and 54.3 years for control and older donors, respectively (P < 0.001). Baseline mean creatinine level was 0.82 mg/dL for controls and 0.84 mg/dL for older donors (P = 0.78). Complications in controls and the older group were 18% and 17%, respectively. One-year transplant survival was 100% for the controls and 96% for the older group. Average creatinine level at longer follow-up of 19 months for controls and 23 months for the older group (P = 0.34) was 1.22 mg/dL and 1.16 mg/dL, respectively (P = 0.535). CONCLUSION: LDN in donors older than 50 years of age appears safe and demonstrates similar outcomes compared with the control cohort of patients younger than 50 years. Age between 50 and 65 years should not exclude a potential donor who otherwise satisfies donor nephrectomy criteria.

Lessons learned from a case of calf compartment syndrome after robot-assisted laparoscopic prostatectomy.

Robot-assisted laparoscopic prostatectomy is rapidly gaining favor as a minimally invasive method to surgically address prostate cancer. The sophisticated equipment and unique positioning requirements of this technology require exceptional preparation and attention to detail to minimize the chance of surgical complications. We present the case of a 57-year-old man who developed left calf compartment syndrome after (robot-assisted laparoscopic prostatectomy) requiring fasciotomies. We use this example to highlight specific areas of risk unique to the da Vinci Surgical System® using intraoperative photos to show danger areas as well as review basic positioning requirements common to all prolonged pelvic surgeries performed in Trendelenburg position.

Complications of laparoscopic renal surgery.

PURPOSE: Laparoscopic renal surgery has become a standard of care over the past decade worldwide. Although more complex laparoscopic renal procedures are being routinely performed worldwide today, complications can occur with any laparoscopic operation. Intraoperative and postoperative complications may occur in patients undergoing laparoscopic renal procedures by urologic surgeons with all degrees of laparoscopic experience. We reviewed the complication rate in patients undergoing laparoscopic renal procedures at a single institution by an experienced laparoscopic surgeon. MATERIALS AND METHODS: We retrospectively reviewed the electronic medical records of patients who underwent laparoscopic renal surgery at the University of Iowa from August 2001 to November 2008. RESULTS: Four hundred twenty-one consecutive laparoscopic renal operations were performed by a single surgeon, consisting of 168 radical nephrectomies, 99 donor nephrectomies, 52 simple nephrectomies, 66 partial nephrectomies, and 36 nephroureterectomies, with a total of 52 complications (12.3%): 20 (11.9%) for radical nephrectomy, 9 (9%) for donor nephrectomy, 3 (5.8%) for simple nephrectomy, 12 (18.2%) for partial nephrectomy, and 8 (22.2%) for nephroureterectomy. The vast majority of complications were minor and resulted in no residual disability. CONCLUSIONS: Despite its advantages, laparoscopic renal surgery is not without its inherent risk of complications for the patient, and a thorough informed consent is crucial to maintain realistic patient expectations. Our results reveal complication rates comparable to those of published series in the literature.

Robotic-assisted laparoscopic reconstruction of the upper urinary tract: tips and tricks.

OBJECTIVES: To examine whether simple tips and tricks provided in this manuscript and video make robotic reconstruction of the urinary tract possible from the renal calyx to the bladder. The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) has been widely accepted by urologists for complex reconstructive maneuvers such as radical prostatectomy and pyeloplasty. METHODS: The manuscript and accompanying video outline tips and tricks for patient selection, patient evaluation, port placement, dissection techniques, robotic docking, ureteral repair, and stent management for complex urinary tract reconstruction of the upper urinary tract from the level of the renal calyx to the bladder. RESULTS: Modifications such as port placement, robotic docking techniques, and ureter reconstruction have simplified the technique of complex robotic-assisted laparoscopic reconstruction of the urinary tract. CONCLUSIONS: Numerous scenarios can be encountered during robotic-assisted laparoscopic repair of the upper urinary tract. Simple tips and tricks provided in this manuscript and video make robotic reconstruction of the urinary tract possible from the renal calyx to the bladder.

Laparoscopic management of caliceal diverticulum.

INTRODUCTION: Minimally invasive approaches for the treatment of symptomatic caliceal diverticula have become the standard of care. Laparoscopy has been embraced by many urologists and now accounts for many commonly performed approaches to urologic surgery. The laparoscopic approach to treating symptomatic caliceal diverticula adds yet another tool in the urologist's armamentarium for this pathologic entity. MATERIAL AND METHODS: Laparoscopy for symptomatic caliceal diverticula can be performed on both anteriorly and posteriorly located lesions using either an intraperitoneal or extraperitoneal approach. The goals of the laparoscopic approach are similar to that of percutaneous surgery; the overlying capsule and parenchyma are excised, stones, if present are removed, and the cavity marsupialized. RESULTS: The success rate for laparoscopically treated symptomatic caliceal diverticula is good with greater than 90 percent rates of cavity obliteration and stone removal and an approximately 75 percent rate of symptom resolution. CONCLUSIONS: Minimally invasive approaches to urologic disease continue to advance. The laparoscopic approach to treating symptomatic caliceal diverticula provides yet another reliable method for treating this problem and should be considered by urologists versed in laparoscopic technique.

Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeons.

PURPOSE: With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy. MATERIALS AND METHODS: We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring and credentialing. RESULTS: Proctoring is an essential mechanism for robot assisted radical prostatectomy institutional credentialing and should be a prerequisite for granting unrestricted privileges on the robot. This should be differentiated from preceptoring, wherein the expert is directly involved in hands-on training. Advanced technology has opened new avenues for long-distance observation through teleproctoring. Although the medicolegal implications of an active surgical intervention by a proctor are not clearly defined, the role as an observer should grant immunity from malpractice liability. CONCLUSIONS: The implementation of guidelines and proctoring recommendations is necessary to protect surgeons, proctors, institutions and, above all, the patients who are associated with the institutional introduction of a robot assisted radical prostatectomy program. With no current guidelines we anticipate this article will serve as a catalyst of interorganizational discussion to initiate regulatory oversight of surgeon certification and proctorship.

Laparoscopic renal tumor cryoablation: appropriate application of real-time ultrasonographic monitoring.

BACKGROUND AND PURPOSE: Many authors who report outcomes of laparoscopic cryoablation for renal tumors comment that real-time intracorporeal ultrasonographic monitoring of the ice-ball formation is imperative. In our experience, ultrasonographic monitoring of the ice-ball formation necessitates significantly more mobilization of the kidney, and the images are difficult to interpret because of artifact and the cryoablation effect on the tissue. We report our intermediate outcomes for laparoscopic cryoablation without real-time ultrasonographic monitoring of the ice ball. PATIENTS AND METHODS: Between December 2002 and May 2007, 27 patients underwent laparoscopic renal cryoablation. The cryoablation approach was based on tumor location and surgeon preference. Lesions were identified and overlying fat was excised, without further mobilization. Real-time ultrasonographic measurement and mapping of the renal lesion were performed. All lesions were biopsied before cryoablation. A double 10-minute freeze-thaw cycle was performed. Postoperative follow-up comprised serial imaging at months 1, 3, 6, and 12 and yearly thereafter. RESULTS: Mean patient age was 70.1 years with a mean renal tumor size of 2.2 cm. Sixteen (59.3%) patients had more than three comorbidities and six (22.2%) patients had two comorbidities with at least 1 previous intra-abdominal surgery. An average of four cryoablation probes were used per lesion. The serum creatinine level was 1.3 mg preoperatively and 1.4 mg at last follow-up. At follow-up of 22 months, there were no local recurrences and 1 (3%) metastatic lesion. CONCLUSION: Laparoscopic cryoablation of small renal masses continues to be a safe and effective technique, even without the use of real-time ultrasonographic monitoring of the ice ball.

Hurdles to helium gas laparoscopy and a readily available alternative.

BACKGROUND AND PURPOSE: Although multiple series of helium insufflation-assisted laparoscopic surgery are reported, we encountered difficulty at many levels when arranging a laparoscopic nephrectomy with helium insufflation. We present our experience with attempting to use helium gas as an insufflant and our successful use of argon gas as an adjunct to CO(2) insufflation with a case report as illustration. MATERIALS AND METHODS: The patient is a 66-year-old man with a progressively enlarging 3.1-cm right renal mass. His history is significant for severe chronic obstructive pulmonary disease, necessitating home oxygen and frequent cycles of steroids. In line with the patient's desire for a minimally invasive procedure, we scheduled a laparoscopic nephrectomy with helium gas. Helium tanks need specialized adapters (yoke) to connect to laparoscopic insufflators; once the yoke was located, we were informed that helium is not approved by the Food and Drug Administration for use as an insufflant and we could not proceed with its use without a full hospital institutional review board review. We elected to use low-pressure CO(2) insufflation augmented by argon gas insufflation via the argon beam coagulator. RESULTS: The patient tolerated the low-pressure CO(2) /argon gas pneumoperitoneum without difficulty. There were no significant changes in the hemodynamic variables throughout the procedure. This patient was extubated at the completion of the procedure, and there were no intraoperative or postoperative complications. CONCLUSIONS: Although numerous reports and case series exist regarding the use of helium as an alternate insufflation agent to CO(2), the logistics of obtaining the correct helium yoke and hospital approval are cumbersome for this rarely indicated agent. A far simpler alternative, with similar physiologic effects, is the use of argon gas as an adjunct to CO(2) insufflation, or in lieu of CO(2) insufflation.

Robot-assisted laparoscopic excision and ureteroureterostomy for congenital midureteral stricture.

Congenital ureteral strictures most commonly occur at the proximal and distal segments of the ureter. Congenital midureteral stricture is a rare entity that is usually detected by prenatal ultrasonography and repaired in infants. We present the case and video of a congenital midureteral stricture in a 20-year-old woman who presented with a severe episode of pyelonephritis. The congenital midureteral stricture was successfully managed with robot-assisted laparoscopic excision and ureteroureterostomy.

Laparoscopic donor nephrectomy.

Since it first was performed in 1995, laparoscopic donor nephrectomy (LDN) has grown to be the standard of care in most transplant centers in the United States. This article reviews the current indications, selection criteria, surgical approaches, outcomes, and complications of LDN.

Prospective evaluation of factors affecting operating time in a residency/fellowship training program incorporating robot-assisted laparoscopic prostatectomy.

BACKGROUND AND PURPOSE: A current dilemma is how to incorporate robot assisted laparoscopic radical prostatectomy (RALP) into residency/fellowship programs while containing costs and maintaining acceptable operative times. We prospectively analyzed factors that affect the time of nine separate RALP steps performed in a residency/fellowship training program incorporating the da Vinci robot. MATERIALS AND METHODS: A prospective evaluation of 50 consecutive RALP performed by a single surgeon while incorporating trainees was completed. RALP was divided into nine segments, and time of each segment was recorded in minutes. Who performed each portion of the procedure (resident, fellow, or attending surgeon) was also analyzed. The effects of clinical and prostate cancer characteristics were analyzed statistically to investigate associations with procedure completion times for each of the nine segments. Outcomes, including complications and urinary continence, were recorded. RESULTS: Mean age was 58 years, and body mass index was 30 kg/m(2). Mean prostate size was 49.2 grams. Nine patients (18%) had pathologic T(3) disease, and 10 patients (20%) had positive surgical margins. Median total operative time was 276 minutes (range 245-330 min). There was no statistical association with any clinical parameter prolonging total operative time or those of the nine individual steps of the operation. Locally weighted smooth time plots demonstrate stable decreases in all segments with experience. The slowest decreases were seen in bladder neck and neurovascular bundle times. Anastomosis time fluctuated the most. CONCLUSION: RALP can be incorporated successfully into a residency/fellowship training program with acceptable operative times and outcomes even while the supervising physician is on his "learning curve."

Robotics in urology: past, present, and future.

The modern-day urologist is continually armed with new instruments and technology aimed at decreasing the overall invasiveness of urologic procedures. Robotic technology is aimed at improving clinical outcomes by correcting human technical inadequacies such as hand tremors and imprecise suturing. The first reported use of robotics to assist with surgery was in 1985, and the first use of robotics in urology was published in 1989. The currently utilized master-slave system (da Vinci Robotic Platform), Intuitive Surgical, Sunnyvale, CA) has popularized robotic surgery for use in numerous urologic conditions including prostate cancer, bladder cancer, renal cancer, uretero-pelvic junction obstruction, and pelvic prolapse. New developments in robotic technology may revolutionize many other aspects of urology including percutaneous renal access and rounding on patients after surgery. This review provides a brief overview of the history of robotics in urology, a description of the da Vinci surgical system and its current utilization as well as limitations, and a review of evolving robotic technology in the field of urology.

Fellowship in endourology, the job search, and setting up a successful practice: an insider's view.

The field of endourology, which encompasses genitourinary endoscopy and percutaneous, laparoscopic, and robotic surgery, has advanced rapidly over the past quarter century, causing endourology to be considered a subspecialty of urology. The Endourological Society, which is recognized by the American Urological Association, offers numerous clinical and research fellowship opportunities throughout the world. The decision to seek postresidency fellowship training in endourology is complex as is the process of seeking subsequent employment. We offer guidance on the decision-making process to obtain fellowship training as well as on early steps into subsequent academic or private practice settings.

Systemic and cell-specific immune response to laparoscopic and open nephrectomy in porcine model.

PURPOSE: To determine differences in the systemic and cell-specific immune response to open and laparoscopic nephrectomy in the porcine model. MATERIALS AND METHODS: Twenty male pigs (25-40 kg) were vaccinated with human adenovirus containing ovalbumin (Ova) and 3 weeks later underwent a sham procedure (N = 4), laparoscopic nephrectomy (LN)(N = 8), or open nephrectomy (ON) (N = 8). Blood was collected after anesthesia induction and immediately and 24 and 48 hours postoperatively and assayed for complete blood count (CBC), cortisol, and C-reactive protein (CRP). Natural killer (NK) cells were isolated and stimulated in vitro for 48 hours with polyinosinic:polycytidylic acid (Poly I:C) and interleukin (IL)-2 to determine cytotoxic activity. Peripheral blood mononuclear cells (PBMC) were isolated for flow cytometry staining with CD8, CD4, and CD25 markers. Additional PBMCs were stimulated in vitro with Ova and ConA for 48 hours to measure the production of IL-10 and interferon (IFN)-gamma and a thymidine-incorporation assay to determine T-cell proliferation. RESULTS: One animal in the ON group had signs of infection preoperatively and was removed from analysis. The LN took significantly longer than ON or sham nephrectomy (P = 0.002). Blood loss and animal weight were similar in the three groups. The CRP concentration increased more in the ON than the LN and sham-treatment groups in the first 48 hours (P = 0.01). No statistical differences were seen in the elevation of white blood cells or cortisol concentration. All groups demonstrated a decrease in the cytotoxic activity of NK cells postoperatively, with a significantly greater decrease in the sham-treated animals (P = 0.004). The LN group demonstrated greater T-cell activation than the ON and sham-treatment groups with both CD4(+) (P = 0.002) and CD8(+) (P = 0.028) cells increasing their expression of the activation marker CD25. The thymidine-incorporation assay demonstrated decreased T-cell proliferation in the ON group when stimulated with ConA (P = 0.014). Production of IL-10 decreased in the sham-treated and LN animals while increasing after ON. There was no difference in IFN-gamma among the groups. CONCLUSIONS: In a porcine model, ON produces higher CRP concentrations postoperatively, a larger decrease in T-cell proliferation ability, and more IL-10 activity than LN or sham treatment. Animals undergoing LN demonstrated greater T-cell activation postoperatively. White blood cell counts, serum cortisol concentration, and production of IFN-gamma were similar among the groups. These findings suggest ON causes greater immune suppression than LN in the porcine model.

State-of-the-art surgical management of renal cell carcinoma.

There is a recognizable increase in the incidence of renal cell carcinoma and a parallel rise in the surgical management of renal cell carcinoma has occurred. However, recent literature shows that not all small, suspected renal cell carcinoma needs to be treated surgically, especially in elderly patients or those with multiple medical comorbidities. The surgical options for renal cell carcinoma have expanded from traditional open nephrectomy to partial nephrectomy and, at present, more recent outcomes data are available for the laparoscopic versions of these surgeries. Short-term results of thermal ablative technology (radiofrequency and cryoablation) show real promise as minimally invasive therapies. This review examines the most up-to-date outcomes and future directions of the surgical management of renal cell carcinoma.

Multi-institutional survey of laparoscopic ureterolysis for retroperitoneal fibrosis.

OBJECTIVES: Medical therapy often fails to cure benign retroperitoneal fibrosis (RPF), necessitating a surgical approach. Preoperative and postoperative adjuvant medical therapy and the timing of surgical intervention are not well-established. We surveyed centers of laparoscopic excellence to determine the current practices in the treatment of RPF. METHODS: Surveys were sent to all institutions with Endourological Society-recognized fellowships. The data collected were analyzed for trends in the treatment of RPF. Additional information was collected from participating institutions to better characterize the experience with laparoscopic ureterolysis and adjunctive medical management. RESULTS: Of the surveys sent out, 17 completed surveys were returned (41%). A total of 73 patients had been treated for RPF. Most centers (13 of 17) used a conventional laparoscopic approach with rare conversion to hand assistance. The medical management of RPF was directed by urologists, rheumatologists, or other specialists in 59%, 24%, and 18% of institutions, respectively. Steroid therapy was administered preoperatively by 15 of 17 centers. Postoperatively, 10 of 17 centers continued treatment with steroids and/or cytotoxic agents. Eight institutions provided data on 46 renal units in the second part of the study. The success rate of laparoscopic ureterolysis per renal unit was 83% (38 of 46). No difference was seen in the outcomes of patients who received adjuvant medical therapy compared with those who did not (16 of 19 versus 22 of 27; P = 0.48) after a mean follow-up of 17.7 months. CONCLUSIONS: The results of this study have shown that no uniform treatment algorithm exists for RPF at centers of laparoscopic excellence. Most institutions recommended an attempt at steroids followed by laparoscopic ureterolysis. Laparoscopic ureterolysis had a high success rate, and adjuvant medical therapy did not appear to contribute to the success rate.