Robot-assisted Transplanted Ureteral Stricture Management.

OBJECTIVE: To assess the feasibility of robot-assisted transplanted ureteral reimplantation as a minimally invasive alternative to open surgery. MATERIAL AND METHODS: Between August 2015 and March 2016, 5 patients presented with transplanted ureteral strictures after failure of a previous endoscopic management. All patients underwent robot-assisted ureteral reimplantation. Patients' demographics, perioperative outcomes, and complications are reported. RESULTS: All patients presented with deterioration of kidney function with or without recurrent urinary tract infection. Two patients had short strictures (<1 cm) and 2 had long strictures (>1 cm), whereas 1 patient had a nitinol ureteral stent in situ. The location of the stricture varied among these patients with 3 distal and 1 proximal. Intraoperatively, 3 patients had a modified Lich-Gregoir reimplantation and 2 patients had a pyelovesicostomy. The mean operative time was 164 (±52) minutes. There were no intraoperative complications, conversion to open surgery, or significant blood loss necessitating blood transfusion. There were no urine leaks in the immediate or late postoperative period. One patient developed a Clavien grade IVa complication (sepsis). The median length of stay, the duration of catheterization, and the duration of stenting were 1 day (range 1-5 days), 7 days (range 6-14 days), and 39 days (range 25-51 days), respectively. After a median follow-up of 79 days (range 40-139 days), no strictures or delayed leakages were identified. CONCLUSION: Robot-assisted transplanted ureteral reimplantation is technically feasible. With a larger number of cases and a longer follow-up, robot-assisted transplanted ureteral reimplantation may provide a new and effective, minimally invasive alternative for the treatment of this complex surgical problem.

Temporary prostatic urethral stenting as a provocative tool to determine surgical eligibility in complex bladder outlet obstructed patients: our initial experience.

BACKGROUND/AIMS: To evaluate the usefulness of a temporary prostatic urethral stent to determine which complex surgical patients would benefit from definitive surgical management of their benign prostatic hyperplasia. METHODS: We retrospectively analyzed our benign prostatic hyperplasia database and identified all patients that received at least one temporary prostatic urethral stent between April 2008 and December 2010. RESULTS: Forty Spanner(TM) stents were placed in 20 patients. Mean age was 78.1 years and prostate size was 62.1 cm(3). Urinary retention was present in 60% (12/20) of patients. No statistically significant changes in mean maximal flow rate, average flow rate, and post void residual was noted. Seven patients (35%) did well with the stent and progressed to definitive surgical management whereas 10% of the cohort (2/20) leaked urine with the stent in place and subsequently went back to catheter management. Another 30% (6/20) were unable to tolerate the stent while 1 patient passed away unrelated to the stent. CONCLUSIONS: The use of the temporary prostatic urethral stent provided a good provocative test that enabled patients to experience what their voiding status would be if they were to undergo definitive surgical management.

Impact of margin status at 37 months after robot assisted radical prostatectomy.

INTRODUCTION: We evaluate the impact of margin length, location, and pathologic stage on biochemical recurrence (BCR) after robot assisted radical prostatectomy (RARP) at 37 months of follow up. MATERIALS AND METHODS: A total of 1420 patients underwent a robot assisted radical prostatectomy between March 2004 and May 2010. Patients who received adjuvant therapy, those who never achieved an undetectable prostate-specific antigen (PSA), and those who had less than 18 months of follow up were excluded. Patients were then divided and evaluated based on margin status. RESULTS: In total, 419 patients were included in the analysis. Eighty-three had a positive surgical margin (PSM) (19.8%), 336 had a negative surgical margin (NSM) (80.2%). The overall mean follow up was 37 months. On multivariate analysis the Gleason sum and PSM were independent predictors of BCR. Margin length and location had no significant difference on the rate of BCR. Patients with a PSM and pT2 disease had an increased rate of BCR compared to pT2 and NSM. The relative risk of BCR was 2.03 and 3.21 for patients who have a PSM versus a NSM, overall and in those with pT2 disease respectively. No different BCR is seen in pT2 PSM versus ≥ pT3 NSM; or ≥ pT3 PSM versus NSM. CONCLUSION: With 37 months follow up; positive surgical margin and postoperative Gleason sum impact the rate of BCR. Location and length of the PSM do not appear to have an impact on BCR. There was an increased risk of BCR with PSM, especially in pT2 disease.

A multiinstitutional study of the effects of medical therapy for lower urinary symptoms on the perioperative outcomes of holmium laser enucleation of the prostate.

OBJECTIVE: The purpose of this research was to examine the influence of 5ARI and other benign prostatic hyperplasia medical therapies on the perioperative outcomes after holmium laser enucleation of the prostate (HoLEP). During HoLEP, the identification of the planes between the transitional and peripheral zones of the prostate is paramount to the success of the procedure. It has been proposed that delineating the prostate capsule may be more difficult after the use of 5-alpha reductase inhibitor (5ARI) medications. METHODS: A retrospective review of patients who underwent HoLEP was performed. Patients were stratified according to their preoperative medication usage. Patient characteristics, pretreatment prostate characteristics and symptom scores, perioperative parameters and complications, and posttreatment symptoms scores were evaluated. RESULTS: There were 176 patients analyzed; 52 (29%) were on no medications, 54 (31%) were on an alpha-blocker (AB) alone, 13 (8%) were on a 5ARI alone, and 57 (32%) were on both a 5ARI and an AB. Enucleation rate (resected volume/resection time) was significantly faster in the combination group. The preoperative prostate-specific antigen value was significantly higher in the 5ARI group. A trend in the lower hemoglobin change was seen favoring the 5ARI group, but this did not reach statistical significance. Evaluating the groups based on the use of 5ARIs either alone or in combination vs no 5ARI confirmed that 5ARI was associated with a significantly faster enucleation rate. CONCLUSION: Preoperative 5ARI use does not appear to adversely alter the outcomes during HoLEP.

Incontinence after radical prostatectomy: a patient centered analysis and implications for preoperative counseling.

PURPOSE: Incontinence after radical prostatectomy is common yet poorly defined in the current literature. We aimed to accurately characterize incontinence after robot-assisted radical prostatectomy to achieve improved preoperative patient counseling. MATERIALS AND METHODS: After receiving institutional review board approval we performed a cross-sectional survey of the first 600 patients with prostate cancer who underwent robot-assisted radical prostatectomy at our institution. The International Consultation on Incontinence Modular Questionnaire-Lower Urinary Tract Symptoms Quality of Life and Urinary Incontinence Short Form were used to evaluate incontinence and quality of life after robot-assisted radical prostatectomy. Surveys were mailed by a third party. Data were analyzed on the prevalence of incontinence after robot-assisted radical prostatectomy. More specifically we characterized in detail the nature of incontinence and its effect on quality of life. RESULTS: The response rate was 68% (408 of 600 participants). Response time since surgery was 2.5 months to 4 years. Overall incontinence bother scores and ratings of life interference were quite low. Patients reported that most incontinence occurred during physical activity but 35% reported interference with sleep. Of the patients 31% experienced some anxiety due to urinary difficulties and 51% had to occasionally change clothes due to leakage. Patients did not report much interference with traveling, visiting friends or family and family life. The most bothersome aspects of incontinence were its effects on partner relationship, sexual life and energy levels. CONCLUSIONS: Despite patient concerns of incontinence after prostatectomy they report little interference with quality of life.

Different approaches to an inguinal hernia repair during a simultaneous robot-assisted radical prostatectomy.

OBJECTIVES: To determine if different approaches to an inguinal hernia repair (robotic, laparoscopic, or open) results in different outcomes during a simultaneous robot-assisted radical prostatectomy (RARP). METHODS: We performed a retrospective review of a prospectively generated database of all RARPs performed at our institution. Patients who had a simultaneous inguinal hernia repair were identified. We compared them to an age-matched and body mass index-matched cohort who underwent RARP alone. We also compared outcomes between robotic versus laparoscopic versus open inguinal hernia repair. RESULTS: A total of 1224 RARPs were performed between March 2004 and September 2009. Eighteen patients had simultaneous inguinal hernia repairs during their RARP performed by a general surgeon (5 laparoscopic, 8 open, and 5 robotic). When compared with the cohort who underwent RARP only, there were no statistically significant differences in blood loss, length of stay, or complications. The control group had a significantly shorter OR time (179.5 vs. 215.5 minutes, p = 0.007). When comparing the different approaches of an inguinal hernia repair, the only statistically significant differences noted were body mass index and operative time. Operative time was longer in open versus robotic inguinal hernia repair (74 vs. 31.6 minutes, p = 0.006). There were only two recurrences, both after the simultaneous open inguinal hernia repair. CONCLUSIONS: Simultaneous inguinal hernia repair is a safe and feasible operation to perform during RARP. Although it does extend overall operative time, approaching the repair robotically is quicker than an open approach. A randomized study is needed to truly determine if one approach has better outcomes than the rest.

Bleeding after holmium laser enucleation of the prostate: lessons learned the hard way.

OBJECTIVE: To examine specific causes of postoperative bleeding requiring transfusion after holmium laser enucleation of the prostate (HoLEP) in order to enhance preoperative screening and counseling. MATERIALS AND METHODS: After Institutional Review Board (IRB) approval, a retrospective review of a single surgeon's experience of 130 consecutive HoLEPs was performed to specifically examine patients requiring perioperative blood transfusions. All patients from August 2007 to April 2009 who underwent a HoLEP at our institution since its inception were included. These patients' charts were reviewed to gain insight into their bleeding diathesis. A case series report was compiled and compared with the relevant published literature. RESULTS: Of the 130 patients, eight (6.7%) were found to require transfusion postoperatively. Four of these patients required a second operation for completion. These patients had a variety of causes for increased bleeding and subsequent transfusion including: chronic anticoagulation (n = 1), significant cardiac disease requiring maintenance of hemoglobin (n = 4), sepsis with secondary disseminated intravascular coagulation (n = 1), large prostate size (>150 g) (n = 4), underlying prostate cancer (n = 1) and inadequate anesthesia during the procedure leading to patient movement (n = 1). All patients made a full recovery with satisfactory urinary symptom improvement except for one patient with residual incontinence at last follow-up. CONCLUSIONS: Despite the many benefits of holmium laser enucleation, all patients should be counseled regarding the real potential for postoperative blood transfusion. When feasible, any known bleeding risk should be minimized by the surgeon as long it is done safely for the benefit of the patient considering their co-morbidities.

Older age does not impact perioperative complications after robot-assisted radical prostatectomy.

To determine whether men aged 70 years and older had more perioperative complications after robot-assisted radical prostatectomy (RARP) compared with younger patients, a retrospective review was performed on patients who underwent RARP between March 2004 and September 2009. Subjects were stratified according to age into four groups (age 30-49, 50-59, 60-69, and ≥70 years). American Society of Anesthesiologists (ASA) scores were obtained. Complication rates in the perioperative period, transfusion rates, and length of stay were compared. Complications were classified using the previously validated Clavien system. There were a total of 293 patients aged 70 years and older amongst the 1,223 total subjects. ASA comorbidity scores did vary significantly amongst the different age groups, and there was modest correlation noted between ASA and age. There was no statistically significant difference amongst complication rates in men aged 70 years and older (15%) compared with the other cohorts (P = 0.832). There was also no significant difference in transfusion rates (P = 0.170) or length of stay (P = 0.131). Patients with higher ASA scores (ASA 3-4) had more Clavien I-II complications compared with patients with ASA scores of 1-2 (15.5% versus 10.3%, P = 0.03). There was no difference in transfusion rates or length of stay between the ASA scores. There are no more complications in men aged 70 years and older compared with men <70 years of age undergoing robot-assisted radical prostatectomy. RARP is a safe treatment option to offer to the selected elderly patient.

Robot-assisted radical cystectomy versus open radical cystectomy: a complete cost analysis.

OBJECTIVES: To perform a complete cost analysis comparing robot assisted radical cystectomy (RARC) versus open radical cystectomy (ORC). MATERIAL AND METHODS: After institutional review board approval for data collection, we prospectively recorded perioperative outcomes and costs, such as hospital stay, transfusion rate, readmission rate, and medications for consecutive patients undergoing RARC or ORC. Using actual cost data, we developed a cost decision tree model to determine typical perioperative costs for both RARC and ORC. Multivariate sensitivity analysis was performed to elucidate which variables had the greatest impact on overall cost. Breakeven points with ORC were calculated using our model to better evaluate variable influence. In addition to the above modeled analysis, actual patient costs, including complications 30 days from surgery, were also compared for each procedure. RESULTS: Our model analysis showed that operative time and length of stay had the greatest impact on perioperative costs. Robotic cystectomy became more expensive than open cystectomy at the following break-even points: operating room (OR) time greater than 361 minutes, length of stay greater than 6.6 days, or robotic OR supply cost exceeding $5853. RARC was 16% more expensive when only comparing direct operative costs. Interestingly, actual total patient costs revealed a 38% cost advantage favoring RARC due to increased hospitalization costs for ORC in our cohort. CONCLUSIONS: RARC can provide a cost-effective alternative to ORC with operative time and length of stay being the most critical cost determinants. Higher complication rates with ORC make total actual costs much higher than RARC.

Robot-assisted radical cystectomy: intermediate survival results at a mean follow-up of 25 months.

OBJECTIVE: To assess the overall and disease-specific survival rates of patients undergoing robot-assisted radical cystectomy (RARC) compared with historical open cystectomy. PATIENTS AND METHODS: Survival, pathological and demographic data were collected on all patients undergoing RARC for bladder cancer from both Tulane University Medical Center and Mayo Clinic Arizona. Of a total of 80 RARCs we only included those with a follow-up of > or =6 months from surgery. Survival curves were compared with those from historical series of open cystectomy. RESULTS: Of the 80 patients 59 were identified as having a follow-up of > or =6 months from the date of surgery. The mean (range) follow-up was 25 (6-49) months. Overall survival rates at 12 and 36 months were 82% and 69%, respectively, and disease-specific survival rates were 82% and 72% at 12 and 36 months, respectively. These results are comparable to survival rates from open cystectomy. As expected, patients with lymph node-positive disease fared worse than those with lymph node-negative disease. Patients with extravesical lymph node-negative disease (pT3, pT4) fared worse than patients with organ-confined lymph node-negative disease. Also, patients with lymph node-positive disease fared worse than those with extravesical lymph node-negative disease, which is consistent with historical results of open cystectomy. CONCLUSIONS: RARC has a comparable survival rate to open cystectomy in the intermediate follow-up. Further study with a longer follow-up and more patients is necessary to determine any long-term survival benefits.

Outpatient prostatectomy: too much too soon or just what the patient ordered.

OBJECTIVES: To evaluate the feasibility of performing a robot-assisted radical prostatectomy (RARP) as an outpatient procedure while maintaining patient satisfaction and safety. Herein we report our experience, selection criteria, and discharge criteria for outpatient RARP. METHODS: We performed a prospective study with 11 patients undergoing extraperitoneal RARP. These patients were counseled before the procedure that they would go home the same evening of the procedure. The patients were then surveyed by a third party shortly after they returned home, using the Patient Judgement System-24, a previously validated instrument for patient satisfaction. Sociodemographic data, comorbidities, and outcomes were collected for analysis. RESULTS: All patients were successfully discharged the same day of surgery. Mean patient age was 62.2 years with a mean body mass index of 26 kg/m(2). Mean operative time was 117.6 minutes, console time was 76.7 minutes, and estimated blood loss was 168.2 mL. Mean indwelling catheter time was 7.5 days. No complications occurred in this series of patients. Satisfaction was unanimously high in all patients surveyed, with most scores over 90% on the Patient Judgement System-24. No patient reported any ill effects from the shortened stay or felt rushed to leave the hospital. CONCLUSIONS: The early experience with extraperitoneal RARP as a same day surgery is promising. Preoperative patient counseling and selection is paramount. Patient satisfaction is not adversely affected by the shortened stay. Surgeon experience, assessment of intraoperative findings, and adequate postoperative assessment are essential.

Interval from prostate biopsy to robot-assisted radical prostatectomy: effects on perioperative outcomes.

OBJECTIVE: To determine whether shorter intervals (<4 and 6 weeks) between prostate biopsy and robot-assisted radical prostatectomy (RARP) have a detrimental effect on perioperative outcomes, as recent studies showed that open RP shortly after prostate biopsy does not adversely influence surgical difficulty or efficacy, but RARP relies solely on visual cues rather than tactile sensation to determine posterior surgical planes of dissection. PATIENTS AND METHODS: A series of 559 patients undergoing RARP from March 2004 to July 2007 was retrospectively reviewed. The interval between prostate biopsy and RARP was determined and patients with intervals of 4 weeks. Patient characteristics and perioperative outcomes were analysed to determine statistically significant differences between the groups. This comparison was then repeated with a 6-week interval, and examined with a multivariate logistic regression analysis. RESULTS: In the 4-week group (509 patients), there was a significantly (P < 0.05) higher rate of complications (18.5% vs 6.9%). In the 6-week group (455 patients) there was a smaller but still significantly higher rate of complications (13.6% vs 6.4%). These results were still significant when controlling for patient and disease characteristics and the 'learning curve'. There was also a significantly higher rate of transfusion in the 6-week group (0.7%). CONCLUSIONS: Our data suggest that RARP should be delayed after prostate biopsy; RARP within 6 weeks of biopsy was associated with a greater risk of complications even when controlling for disease and patient characteristics.

A novel and ergonomic patient position for laparoscopic kidney surgery.

INTRODUCTION: Flank positioning with the patient's ipsilateral arm elevated over the head on an arm board is often used during laparoscopic kidney surgery. There have been reports of brachial plexus neuropraxia, rhabdomyolysis and other complications related to this positioning. Herein we describe our modified positioning technique for laparoscopic renal surgery. METHOD: Beginning in November 2003, all patients undergoing laparoscopic renal surgery have been positioned in the 30 degree modified flank position. The ipsilateral arm on the surgical side is not elevated on an arm board but lies in an ergonomic "sling" position with the elbow flexed slightly greater than 90 degrees. The chest, hips, and knees are secured with tape to allow for extreme table rotation which creates a "true" flank angle relative to the horizontal. RESULTS: Over 1240 cases have been performed utilizing this method, with no events of rhabdomyolysis or neuropraxia secondary to positioning. All patients up to a body mass index (BMI) of 67 kg/m2 have successfully undergone laparoscopic renal surgery with this method without any limitation encountered secondary to positioning. CONCLUSIONS: This novel technique allows for more ergonomic arm positioning as well as significantly decreased pressure on the contralateral down side. The use of extreme table rotation eliminates the need for conventional flank positioning which employs table flexion, arm boards, and axillary rolls. This technique allows for rapid, easy, and safe positioning with no related complications in 1240 laparoscopic kidney cases.

Does a history of previous surgery or radiation to the prostate affect outcomes of robot-assisted radical prostatectomy?

OBJECTIVE: To evaluate retrospectively whether or not previous treatment to the prostate alters the perioperative outcomes from robot-assisted radical prostatectomy (RARP) after the initial 'learning curve', as there are conflicting data on outcomes of RP in patients with previous treatment to the prostate. PATIENTS AND METHODS: We retrospectively reviewed the charts of patients who had RARP between March 2005 and August 2007, and analysed demographic, perioperative variables and pathological data. In all, 510 patient charts were reviewed, identifying 24 patients with a history of previous treatment to the prostate including transurethral resection or incision of the prostate, transurethral microwave therapy, transurethral needle ablation, photoselective vaporization, simple prostatectomy, external beam radiotherapy, brachytherapy, and open bladder neck reconstruction (group 1) and 486 with no previous treatment (group 2). RESULTS: There was no significant difference between the groups in body mass index, clinical stage, grade or prostate volume, but the patients in group 1 were older (70 vs 65 years, P = 0.001). Outcome analysis comparing groups 1 and 2 showed an estimated blood loss of 155 vs 137 mL, length of hospital stay of 2.2 vs 1.5 days, operative duration of 200 vs 186 min and catheter time of 12 vs 8 days, respectively; only the last was statistically significant (P = 0.03). There was an 8.3% and 6.8% complication rate in groups 1 and 2, respectively, and the respective overall positive margin rate was 20.8% and 22.6%. CONCLUSIONS: A history of previous treatment of the prostate does not appear to compromise the perioperative outcomes of RARP.