Learning Curve for Robot-Assisted Laparoscopic Radical Prostatectomy for Pathologic T2 Disease

PURPOSE: To investigate the learning curve for robot-assisted laparoscopic radical prostatectomy (RALP) for pathologic T2 disease, we examined differences in perioperative outcomes according to time period. MATERIALS AND METHODS: Between July 2005 and June 2008, a total of 307 consecutive patients underwent RALP for prostate cancer and 205 patients had pathologic T2 disease. Patients were grouped into 6-month time periods. We collected and examined the patient's perioperative data including age, body mass index (BMI), prostate-specific antigen (PSA), operation time, estimated blood loss, and positive surgical margin. RESULTS: There were no significant differences among the groups in age (p=0.705), BMI (p=0.246), PSA (p=0.425), or prostate volume (p=0.380). Operation time (p<0.001) and estimated blood loss (p<0.001) decreased significantly with time. The positive surgical margin rate also showed a decreasing trend, but this was not significant (p=0.680). CONCLUSIONS: Operation time and estimated blood loss had a steep learning curve during the early 24 cases and then stabilized. A positive surgical margin rate, however, did not have a significant learning curve, although the positive surgical margin decreased continuouslyope

Initial Clinical Experience with Robot-Assisted Laparoscopic Partial Nephrectomy for Complex Renal Tumors.

PURPOSE: Robot-assisted laparoscopic partial nephrectomy (RLPN) is gaining acceptance as an alternative to open partial nephrectomy and laparoscopic partial nephrectomy for small renal masses. However, it still remains a technically challenging procedure even for experienced laparoscopists. Endophytic tumors or renal hilar tumors pose an additional challenge. MATERIALS AND METHODS: We reviewed the medical records of 11 patients (mean age: 49.3 years; range: 31-67 years) who underwent RLPN for small, complex renal masses including hilar tumors and endophytic tumors. RLPN was performed with the Da Vinci(R) surgical system (Intuitive Surgical, Sunnyvale, USA) with three robot arms and intraoperative ultrasonography (Tile-pro(R) System). RESULTS: RLPN was performed successfully without complications in all cases. The mean tumor size was 3.2 cm (range, 1.1-8.0 cm). The mean operative time was 177 minutes (range, 150-260 minutes), and the mean warm ischemia time was 32 minutes (range, 25-41 minutes). The mean estimated blood loss was 177 ml (range, 50-350 ml), and the mean hospital stay was 4 days (range, 3-7 days). Pathology found four patients with clear cell type renal cell carcinoma, one with multilocular multicystic renal cell carcinoma, two with papillary type, one with chromophobe type, and three with angiomyolipoma. CONCLUSIONS: RLPN is a feasible and safe surgery for complex renal tumors. In our experiences, RLPN could be a nephron-sparing surgical option for patients with compromised renal function and it could be an alternative to open partial nephrectomy and laparoscopic partial nephrectomy for a select group of patients.ope

Mechanical property characterization of prostate cancer using a minimally motorized indenter in an ex vivo indentation experiment

OBJECTIVES: To measure the mechanical property of prostatic tissues using a minimally motorized indenter and to determine whether measurable differences in mechanical property exist between cancerous and noncancerous tissues in an ex vivo experiment. METHODS: A total of 552 sites from 46 prostate specimens taken during radical prostatectomy underwent an indentation experiment with a minimally motorized indenter, and the elastic modulus (Young's modulus) of the tissue was estimated. RESULTS: The mean elastic modulus of the regions containing cancer and noncancer was 24.1 ± 14.5 and 17.0 ± 9.0 kPa, respectively. In the noncancerous regions, the prostate was separated into 5 parts according to the post hoc test for comparing the elastic modulus between the 2 groups: part 1, lateral apex; part 2, medial apex; part 3, lateral-mid; part 4, lateral base; and part 5, medial-mid and medial base. In the regions containing cancer tissue, the prostate was also separated into 5 parts: part 1, lateral apex and medial apex; part 2, lateral-mid; part 3, lateral base; part 4, medial base; and part 5, medial-mid. The elastic modulus was greater in the tissue with a Gleason score of 8 than in the other tissue. The elastic modulus was significantly greater in the tissue with a tumor volume >5 cm(3) than in the other tissue. CONCLUSIONS: We determined the elastic moduli of prostatic tissue as a quantitative and objective parameter according to the regions of the prostate, the presence of cancerous tissue, the tumor volume, and the Gleason scoreope

Robotic palpation-based mechanical property mapping for diagnosis of prostate cancer

PURPOSE: The aim of this study was to estimate the mechanical properties (elasticity) of normal and cancer prostate tissues and to develop a tissue elasticity map for the diagnosis and localization of prostate cancer. MATERIALS AND METHODS: A total of 735 sites from 35 radical prostatectomy specimens were used in the experiments using a robotic palpation system, and the elasticities of the specimens were estimated by a tissue characterization algorithm. The estimated elasticities from 21 regions were separated into normal and cancer tissues using the pathological information, and a tissue elasticity map was developed using numerical functions and a nonlinear surface-fitting method. RESULTS: The mean elastic moduli of the normal and cancer tissues were 15.25 ± 5.88 and 28.80 ± 11.20 kPa, respectively. The base region had the highest elasticity, followed by the medial and apex regions. These results demonstrated the ability to separate the cancer tissue from the normal tissue based on its elastic modulus. The tissue elasticity mapping was carried out using the estimated elasticity and nonlinear surface fitting. The proposed map showed the elasticity and was used to estimate the elastic modulus of the prostate at any given region. CONCLUSION: Tissue elasticity may be an important indicator of prostate cancer because the pathologic changes alter the tissue properties, including cell integrity and intercellular matrix. This work provides quantitative and objective information for the diagnosis of prostate cancer. In addition, these results may have implications for the localization of prostate cancersope

복강경 수술의 교육 및 훈련을 위한 환자 장기 모델을 이용한 초기 수술 시뮬레이션 개발

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Robot-assisted laparoscopic radical prostatectomy after previous cancer surgery

Robot-assisted laparoscopic radical prostatectomy has become a frequently used alternative treatment option in the management of prostate cancer. As more operations are performed, more challenging patient conditions are encountered, for example those with previous abdominal cancer surgery. We present our experience of robot-assisted laparoscopic radical prostatectomy (RALP) in patients with previous cancer surgery. Seven patients with a history of previous surgery for malignancy underwent RALP. All the prostatectomies were performed using the da Vinci™ S surgical system by a single surgeon. All operations were approached transperitoneally. We reviewed perioperative data and surgical outcomes retrospectively. The mean age at surgery was 68.43 years (range 63–82). The mean operative time was 214 ± 47.32 min, and the median estimated blood loss was 500 ml (range 200–1,300). The mean hospital stay was 6.57 ± 2.15 days, and the mean duration of catheterization was 8.29 ± 3.09 days. Nerve-sparing procedure and pelvic lymph node dissection were performed in six patients. Rectal injury occurred in one patient who had undergone hemi-colectomy 15 years previously and was resolved by primary closure. Positive surgical margin was found in three patients. Although one patient had an intraoperative rectal injury, RALP in a patient with previous cancer surgery seems to be feasible and safe in experienced handsope

Double primary tumor of the stomach and the prostate managed robotically simultaneously

The occurrence of multiple primary tumors is rare. Here we present a case of a 65-year-old male with a longstanding cardiac condition who presented with synchronous adenocarinoma of the stomach and prostate. Both cancers were managed simultaneously using robot-assisted laparoscopy techniques. Subtotal gastrectomy with gastro-jejunostomy and nerve-sparing radical prostatectomy were performed successfully. Post-operative course was likewise uneventful. Operative and oncologic outcomes were excellent with the patient cancer-free after one year of follow up. We believe the robotic system enabled us to manage this case simultaneously with excellent results.ope

Robotics applied in laparoscopic kidney surgery: the Yonsei University experience of 127 cases

OBJECTIVE: We report our experience on 127 kidney surgeries with the da Vinci surgical system and show the feasibility of a robotics application in a variety of kidney surgeries by both a laparoscopically-trained and a laparoscopically-naïve surgeon. METHODS: Clinical data of patients who underwent kidney surgery with the da Vinci surgical system from September 2006 to April 2009 were reviewed. Data acquired from medical records included patient demographics, operative time, estimated blood loss (EBL), incidence of intraoperative complication, duration of hospital stay, blood transfusion rate, oncological outcomes, and follow-up results. RESULT: One-hundred twenty-seven kidney surgeries have been conducted with the da Vinci surgical system at our institution. Three urologists--1 with formal endourology training, 1 with laparoscopic experience, and 1 laparoscopically naïve--have used it for a variety of procedures involving the kidney. The cases include 65 partial nephrectomies (RPN), 38 radical nephrectomies (RRN), and 24 nephroureterectomies with bladder cuff (RNU). Results on operative time, EBL, incidence of intraoperative injury, duration of hospital stay, and blood transfusion rate are comparable with contemporary studies. CONCLUSIONS: Robotics application in kidney surgery is a viable option for various procedures. Our experience shows it can be safely and effectively conducted by both laparoscopically-trained and laparoscopically-naïve surgeons once they are accustomed to the robotics systemope

Robot Assisted Laparoendoscopic Single-site Surgery for Partial Nephrectomy in Porcine Model

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Initial experience with 50 laparoendoscopic single site surgeries using a homemade, single port device at a single center

PURPOSE: We report our technique of and initial experience with 50 patients who underwent laparoendoscopic single site surgery using a homemade single port device at a single institution. MATERIALS AND METHODS: Between December 2008 and August 2009 we performed 50 laparoendoscopic single site surgeries using the Alexis wound retractor, which was inserted at the umbilical incision. A homemade single port device was made by fixing a size 7 1/2 surgical glove to the retractor outer ring and securing the glove fingers to the end of 3 or 4 trocars with a tie and a rubber band. A prospective study was performed in 50 patients to evaluate outcomes. RESULTS: Of 50 patients 34 underwent conventional laparoendoscopic single site surgery, including radical and simple nephrectomy, and cyst decortication in 8 each, nephroureterectomy in 3, partial nephrectomy and adrenalectomy in 2 each, and partial cystectomy, ureterectomy and ureterolithotomy in 1 each, while 16 underwent robotic laparoendoscopic single site surgery, including partial nephrectomy in 11, nephroureterectomy in 3, and simple and radical nephrectomy in 1 each. Mean patient age was 52 years, mean body mass index was 23.4 kg/m(2), mean operative time was 201 minutes and mean estimated blood loss was 201 ml. Four intraoperative complications occurred, including 2 bowel serosal tears, diaphragm partial tearing and conversion to open radical nephrectomy. One case of postoperative bleeding was managed by transfusion. Surgical margins were negative in the 13 patients who underwent partial nephrectomy. Mean hospital stay was 4.5 days (range 1 to 16). CONCLUSIONS: Our homemade single port device is cost-effective, provides adequate range of motion and is more flexible in port placement for laparoendoscopic single site surgery than the current multichannel portope