Laparoscopic Radical Prostatectomy with a Remote Controlled Robot.

PURPOSE: Robotics in surgery is a recent innovation. This technology offers a number of attractive features in laparoscopy. It overcomes the difficulties with fixed port sites by restoring all 6 degrees of freedom at the instrument tips, provides new possibilities for miniaturization of surgical tasks and allows remote controlled surgery. We investigated the applicability of remote controlled robotic surgery to laparoscopic radical prostatectomy. MATERIALS AND METHODS: Our previous experience with laparoscopic prostatectomy served as a basis for adapting robotic surgery to this procedure. A surgeon at a different location who activated the tele-manipulators of the da Vinci∗ robotic system performed all steps of the intervention. A scrub nurse and second surgeon who stood at patient side had limited roles to port and instrument placement, exposure of the operative field, assistance in hemostasis and removal of the operative specimen. Our patient was a 63-year-old man presenting with a T1c tumor discovered on 1 positive sextant biopsy with a 3+3 Gleason score and 7 ng./ml. preoperative serum prostate specific antigen. RESULTS: The robot provided an ergonomic surgical environment and remarkable dexterity enhancement. Operating time was 420 minutes, and the hospital stay lasted 4 days. The bladder catheter was removed 3 days postoperatively, and 1 week later the patient was fully continent. Pathological examination showed a pT3a tumor with negative margins. CONCLUSIONS: Robotically assisted laparoscopic radical prostatectomy is feasible. This new technology enhances surgical dexterity. Further developments in this field may have new applications in laparoscopic tele-surgery.

Skill assessment of urological laparoscopic surgeons: can criterion levels of surgical performance be determined using the pelvic box trainer?

OBJECTIVES: To correlate between surgeons' experience in urological laparoscopy and their performance of a set of laparoscopic tasks performed on a box trainer in the laparoscopic laboratory. METHODS: 44 urologists participated in this study. A self-administrated questionnaire enquired about their experience in laparoscopy and they were divided to 4 categories: no experience, minimal experience, basic and advanced laparoscopists. Tests consisted of 4 tasks: passage of a ligature, intracorporeal knotting, intracorporeal suturing, and cutting a carton circle out of a square. All tests were supervised and time was recorded for each of the tasks. Histograms were plotted showing the mean time for performance of each task in each experience group. The Kruskal-Wallis analysis of variance was used to assess statistical significance. RESULTS: Seven participants had no previous experience in laparoscopy and 14 had minimal experience. 15 had basic experience and 8 were advanced laparoscopists. No difference in performance was found between the no experience and minimal experience group and they were united and defined as beginners. A significant difference in performance was noted between the beginners, basic and advanced groups, especially when comparing beginners to advanced. Criterion level values of surgical performance drawn from this data were highly discriminative with sensitivity of 71-85% and specificity of 74.2%-88%. CONCLUSIONS: We were able to differentiate between various levels of laparoscopic skills among the participating urologists. Values drawn from such studies could be the basis of criterion level values for technical laparoscopic performance during training programs and before granting laparoscopic privileges to urologists.

Robotic renal surgery.

Robotic technology is an expansion of laparoscopic surgery. Robots can be conceived of as specialized laparoscopic tools; their aim is to improve dexterity of the operating surgeon, and therefore they correspond to computer-enhanced telemanipulator devices. For the patient, the advantage of robotic surgery is essentially the advantage of the laparoscopic approach. It gives surgeons tremendous benefits, however, with its intuitive Endowrist and dexterity. From the patient perspective, the biggest difference is between an open operation and one that uses minimally invasive techniques. The contribution of robotics to the evolution of surgery will be obvious if these new systems increase the number of conventionally trained surgeons performing more complex operations using minimally invasive surgical techniques, or if the outcome data from different centers worldwide suggest that the use of advanced technology permits surgeons to have augmented technical performance.

Cadaveric versus porcine models in urological laparoscopic training.

INTRODUCTION: Laparoscopy performed on anesthetized pigs is an established training model. In this pilot study, we performed laparoscopy on cadavers as a training modality for urologists participating in a laparoscopic seminar. MATERIALS AND METHODS: We compared data from two consecutive laparoscopy seminars performed at our institution. The first included a laparoscopy session performed on pigs. The second was in the same setup, yet laparoscopy was performed on fresh cadavers. We analyzed and compared the trainees' perspectives regarding the 2 modalities using a 5-scale satisfaction questionnaire. RESULTS: Seven trainees attended the cadaveric and 9 the porcine laparoscopy session. The two groups were similar in terms of age and previous laparoscopic and urological experience. The general satisfaction of the two training modalities was high in the two groups, as well as their will for another session of the same kind. Yet the trainees ranked their understanding of the surgical anatomy, laparoscopic technique and use of instruments significantly higher in the cadaveric laparoscopy group (p values were 0.007, 0.006 and 0.032, respectively). CONCLUSIONS: Cadaveric laparoscopy may offer an ideal surgical environment allowing dissection and performance of complete procedures. In this pilot study, we conducted the first reported cadaveric laparoscopy training seminar in urology. The trainees preferred the cadaveric laparoscopy and found it superior to porcine laparoscopy. We believe that cadaveric laparoscopy is an important training tool, which may be added to the armamentarium of urological laparoscopy training courses.

Laparoscopic radical prostatectomy: description of the extraperitoneal approach using the da Vinci robotic system.

PURPOSE: We developed and assessed the feasibility of extraperitoneal laparoscopic radical prostatectomy performed using the da Vinci (Intuitive Surgical, Mountain View, California) robotic system. MATERIALS AND METHODS: In June 2002, 4 consecutive patients with clinically localized prostate cancer underwent extraperitoneal, robotic assisted laparoscopic radical prostatectomy. After development of the extraperitoneal space the surgeon performed laparoscopic prostatectomy from the remote control unit. The assistant aligned and exchanged robotic instruments and used conventional laparoscopic instruments to facilitate prostatectomy. Perioperative data and pathological results were recorded. RESULTS: No difficulties were noted when developing the extraperitoneal space. All additional steps were successfully performed with telerobotics. More distal placement of the robotic ports appeared to improve the feasibility of the extraperitoneal approach. The peritoneum acted as a natural bowel retractor and the distal port placement facilitated use of the assistant ports. Mean operative time was 274 minutes (range 124 to 360). Mean catheterization time and hospital stay were 2.7 and 5.3 days, respectively. A positive margin was observed in 1 patient and pathological stage was pT2 in 3 and pT3 in 1. No postoperative complications or open conversions were observed. CONCLUSIONS: The extraperitoneal approach was feasible with the da Vinci robotic system. Distal port placement for the robot appeared to create an ergonomic environment for the surgeon and assistant and more direct prostatic access. While additional clinical experience is required, the extraperitoneal approach may ultimately provide advantages for robotic and nonrobotic laparoscopic radical prostatectomy.

Prospective evaluation of a 21-sample needle biopsy procedure designed to improve the prostate cancer detection rate.

OBJECTIVES: To evaluate prospectively the diagnostic yield of a 21-sample ultrasound-guided needle biopsy procedure for prostate cancer in patients with elevated serum prostate-specific antigen and/or abnormal digital rectal examination findings. METHODS: Between December 2000 and May 2002, 303 patients underwent 21-sample needle biopsy under local anesthesia, comprising sextant biopsies at a 45 degrees angle, 3 biopsies in each peripheral zone at an 80 degrees angle, 3 biopsies in each transition zone (TZ), and 3 biopsies in the midline peripheral zone. Morbidity was assessed clinically. A short questionnaire was filled out by 90 consecutive patients. RESULTS: The cancer detection rate using 6 biopsy samples (sextant biopsies only), 12 samples (sextant plus lateral biopsies), 18 samples (sextant plus lateral plus TZ biopsies), and 21 samples (sextant plus lateral plus TZ, plus midline biopsies) was 22.7%, 28.3%, 30.7%, and 31.3%, respectively. The 21-sample procedure statistically improved the cancer detection rate by 37.9% relative to the 6-sample procedure. The improvement was most marked in patients with a prostate volume of more than 40 cm(3) (48.3%), patients with Stage T1c prostate disease (44.9%), patients undergoing repeat biopsy (66.2%), and patients with prostate-specific antigen levels greater than 10 ng/mL (38.5%). Adverse effects were infrequent (3%), consisting of prostatitis in 3 patients, acute urinary retention in 6 patients, and rectal bleeding requiring hospitalization in 1 patient taking aspirin. Using the questionnaire, 84% of patients reported macroscopic hematuria for an average of 3.4 days and hematospermia for 12.8 days, and 45% reported minor rectal bleeding lasting 1.1 days. The mean pain score, with a visual analog scale ranging between 0 (no pain) and 10 (intense pain), was 4.56. CONCLUSIONS: A 21-sample needle biopsy procedure increased the prostate cancer detection rate relative to a 6-sample procedure, without increasing morbidity. Patients with elevated prostate-specific antigen values should undergo sextant biopsies and at least 6 additional biopsies in the peripheral zone and 6 in the TZ.

Positive surgical margins in laparoscopic radical prostatectomy: the impact of apical dissection, bladder neck remodeling and nerve preservation.

PURPOSE: We assess the incidence and location of positive surgical margins in a consecutive series of patients who underwent laparoscopic radical prostatectomy. MATERIALS AND METHODS: Between May 1998 and September 2001, 235 men underwent laparoscopic radical prostatectomy at our institution. During this period modifications were made in the technique. We stopped preserving the puboprostatic ligaments during 1999 and stopped preserving the bladder neck during 2000. We compared the incidence of apical and bladder neck margins before and after these changes in surgical technique. Nerve sparing status was documented by the surgeon at the end of the operation and its effect on the incidence of lateral positive margins was evaluated. To concentrate on the surgically induced margins this study focused on pT2 cases. RESULTS: There were 169 pT2 cases and 32 (18.9%) positive margin locations. A constant decrease was noted in the overall incidence of positive margins but, while apical margins were the most abundant in 1998, posterolateral margins were most abundant in 2001. Avoiding bladder neck preservation eliminated positive bladder neck margins in 2001. The overall incidence of positive lateral surgical margins in pT2 cases treated with a nerve sparing procedure was 8.4%. CONCLUSIONS: The experience gained in this procedure led to a decrease in the incidence of positive margins. Wide resection of the bladder neck and cutting the puboprostatic ligaments decreased bladder neck and apical positive margins. Nerve preservation did not increase the incidence of positive margins. These technical modifications may improve the outcome of laparoscopic radical prostatectomy.

Prognostic consequences of the location of positive surgical margins in organ-confined prostate cancer.

INTRODUCTION: The purpose of the present study was to evaluate and compare the risk of progression in organ-confined prostate cancers (stage pT2), according to the location of positive surgical margins. MATERIALS AND METHODS: Between 1988 and 2001, 538 consecutive men underwent radical prostatectomy for localized prostate cancer. All patients had preoperative physical examinations, serum PSA assays (Hybritech assay, N.l. <4 ng/ml) and ultrasound-guided sextant biopsies to confirm diagnosis. Radical prostatectomy specimens were analyzed according to the Stanford protocol. Positive margins were classified as single or multiple and main locations (apex, bladder neck and posterolateral) were noted. Postoperative follow-up data were obtained through routine serum PSA assays. Biochemical recurrence was defined as a single postoperative PSA level >0.2 ng/ml. Biochemical progression was studied in patients with organ-confined tumors (stage pT2) according to the location of the single positive margin. Kaplan-Meier analysis was performed to determine the actuarial biochemical recurrence-free likelihood and the log-rank test was used for statistical analysis. Differences were considered significant when the p value was <0.05. RESULTS: 371 patients had organ-confined tumors, and 60 patients (16.1%) had solitary positive margins (apex 26, bladder neck 14, posterolaterally 20). Eleven patients (18.3%) had biochemical progression. 5-year biochemical free progression was 54.5, 76.9 and 87.9% for apex, bladder and the posterolateral location, respectively (p < 0.05). CONCLUSIONS: In the present study, a positive surgical margin at the apex was associated with worse clinical prognosis compared to the bladder neck and posterolateral locations.

Preparedness in robotically assisted interventions.

For many years, robots have been used in manufacturing to perform a variety of delicate tasks. Their use is now being generalized to other fields, such as biology, domestic applications, and especially medicine, in which they are poised to make a significant contribution. This evolution comes from the progress made in the field of robotics and from recent changes in medical and surgical techniques, namely, developments in medical imaging and a new desire for minimally invasive interventions. This emerging combination of high-precision robotic manipulators, new medical diagnostic techniques, and efficient minimally invasive surgery has not yet been perfected. After a brief discussion of state-of-the-art robotic systems used in urology, this article discusses new challenges presented by robotic minimally invasive surgery. A computer-integrated approach aimed at increasing the efficiency of such interventions through better preparedness is presented. This approach is illustrated by a case study in human nephrectomy and a cardiac animal experiment.

Laparoscopic and robotic surgical training in urology.

The most important change in urology during the past decade was the development of minimally invasive surgery, particularly laparoscopy. However, the main drawback of laparoscopy is a steep learning curve, which results from the significant changes in the surgical environment. Although laparoscopy can provide important advantages for the patient, including decreased length of hospitalization, decreased analgesic requirement, and a shortened postoperative convalescence, one concern has been whether laparoscopic techniques should be learned solely in the operating room. For example, sports, music, and aviation are practiced before an actual performance is ever undertaken. In this review, the advantages and limitations of all available training modalities in minimally invasive surgery are described. Testing basic laparoscopic skills on inanimate models, becoming familiar with the principles of dissection and hemostasis on living animals, and studying surgical anatomy on cadavers should be considered as indispensable and complementary elements for laparoscopic training in the future. In addition, telementoring with the help of modern image processing and virtual reality eventually may become the basis of tomorrow's surgical instruction.

Assessment of surgical technique and perioperative morbidity associated with extraperitoneal versus transperitoneal laparoscopic radical prostatectomy.

OBJECTIVES: To compare the perioperative morbidity and surgical technique of the two main variants of laparoscopic radical prostatectomy: the more often used transperitoneal approach with primary dissection of the plane posterior to the seminal vesicles (TP-LRP) and a purely extraperitoneal approach (EP-LRP). METHODS: Our initial 20 consecutive patients who underwent EP-LRP and the last 20 consecutive patients who underwent TP-LRP were included in this retrospective study. The two groups were well matched for age, American Society of Anesthesiologists score, body mass index, prostate-specific antigen level, and Gleason score. The mean time for completion of the individual laparoscopic steps was assessed for both approaches. RESULTS: With EP-LRP, the mean operative time was shorter (169.6 minutes versus 224.2 minutes, P <0.001) and patients resumed a full diet earlier (mean 1.6 days versus 2.6 days, P = 0.002). The mean total dose and duration of morphine administration were higher in the TP-LRP group, but the difference was not statistically significant (6.0 mg versus 12.8 mg and 0.5 day versus 0.9 day, respectively). The catheter time was nearly identical in the two groups (mean 5.3 days with TP-LRP and 4.2 days with EP-LRP). The incidence of positive margins was not affected by the surgical approach. CONCLUSIONS: These preliminary results suggest that the initial posterior dissection associated with TP-LRP is less efficacious than direct access of the prevesical space during EP-LRP. Measures of perioperative morbidity were at least equivalent, if not superior, for the EP-LRP technique. These findings, together with the significant decrease in operative time with EP-LRP, appear sufficiently important to abandon the transperitoneal technique.