Chirurgia conservativa robotica dei tumori renali: esperienza preliminare monocentrica.

La nefrectomia conservativa è un intervento che ha, come principale scopo, quello di garantire una radicalità oncologica, pur mantenendo la conservazione di parenchima renale funzionante. Le indicazioni sono: Di necessità o imperativa: carcinoma a cellule renali bilaterale sincrono, tumori in pazienti con rene singolo; Profilattica: in pazienti per i quali il futuro preserva una significativa riduzione funzionale del rene contro laterale; Di elezione: neoplasie renali in stadio T1a e rene controlaterale funzionalmente integro per tutti i pazienti; neoplasie in stadio T1b e rene controlaterale funzionalmente integro, a seguito però di attenta valutazione e selezione del paziente. L’esteso utilizzo dell’imaging ha portato all’aumento evidente del numero di nuove diagnosi di piccole masse renali: circa il 60% delle lesioni identificate ogni anno sono infatti di dimensioni inferiori ai 4 centimetri. In quest’ottica la chirurgia nephron-sparing si è evoluta da semplice opzione terapeutica a trattamento standard per le suddette lesioni di piccole dimensioni. Infatti è stato dimostrato che la nefrectomia conservativa ha la stessa efficacia dal punto di vista oncologico rispetto alla nefrectomia radicale, con il vantaggio di ridurre la conseguente possibilità di insufficienza renale. Per questo motivo, nell’ottica di mantenere un obiettivo di mininvasività nell’approccio chirurgico nephron-sparing, diversi studi hanno valutato la possibilità di eseguire tale intervento con la tecnica robotica e si è assistito negli ultimi anni ad un incremento del numero dei chirurghi che eseguono la nefrectomia parziale robotica (RPN). Inoltre il tempo di ischemia renale è il principale fattore chirurgico che determini l’esito funzionale dell’intervento. Nella maggior parte dei lavori in cui si parla di RPN, il clampaggio vascolare è ancora molto utilizzato ed è ritenuto necessario per ridurre le perdite ematiche; tuttavia sappiamo anche, da numerosi lavori, quanto il tempo di ischemia renale possa essere rilevante in termini di impatto sulla funzione renale. Lo scopo di questo studio è dimostrare la fattibilità e la sicurezza degli interventi di RPN senza clampaggio vascolare, riducendo pertanto a zero il tempo di ischemia renale, servendosi di agenti emostatici per consentire l’esecuzione della nefrectomia conservativa senza ischemia. Sono stati selezionati 22 pazienti, 14 maschi e 8 femmine, con diagnosi di massa renale, operati presso la U.O. di Chirurgia Generale Universitaria I dell’Azienda Ospedaliera Universitaria Pisana (AOUP) tra il mese di febbraio del 2009 ed il mese di aprile del 2013. I pazienti selezionati sono stati sottoposti a nefrectomia conservativa con procedura robotica (RPN, Robotic Partial Nephfrectomy). La selezione dei pazienti è stata effettuata avvalendosi del R.E.N.A.L nephrometry score: sono stati candidati alla RPN i pazienti con tumori T1a. L’approccio robotico è stato eseguito con il Da Vinci Surgical System®. L’emostasi è stata eseguita con l’utilizzo di agenti emostatici (FloSeal®, Tabotamp®) e, laddove questi siano risultati non sufficienti, con l’ausilio di punti di sutura in prolene. Sono stati analizzati i risultati operatori, le complicanze e i dettagli anatomopatologici. La funzione renale è stata valutata con il sistema MDRD. Non è stato mai necessario convertire l’intervento in open. La maggior parte delle lesioni (83%) non hanno richiesto il clampaggio vascolare, mentre si è reso necessario solo in quattro casi (17%). Nel gruppo di pazienti che non hanno subito il clampaggio vascolare, i livelli medi di creatinina sierica pre- e postoperatori sono risultati rispettivamente pari a 0.85 mg/dl e 0.83 mg/dl, con una variazione che non è risultata statisticamente significativa. Analoghi risultati sono stati ottenuti per i valori medi di funzione renale (eGFR), che sono risultati rispettivamente pari a 85.9 ml/min/1.73m2 e 87.6 ml/min/1.73m2, con una variazione che non è risultata statisticamente significativa. Nel gruppo di pazienti che hanno subito il clampaggio vascolare, i livelli medi di creatinina sierica pre- e postoperatori sono risultati rispettivamente pari a 0.87 mg/dl e 0.88 mg/dl, con una variazione che non è risultata statisticamente significativa. Analoghi risultati sono stati ottenuti per i valori medi di funzione renale (eGFR), che sono risultati rispettivamente pari a 86.0 ml/min/1.73m2 e 88 ml/min/1.73m2, con una variazione che non è risultata statisticamente significativa. Basandoci sulla nostra esperienza e sui dati pubblicati in letteratura la tecnica di RPN senza clampaggio vascolare si è dimostrata un approccio fattibile e sicuro. L’intervento di RPN con approccio “unclamping” è inoltre particolarmente indicato per i pazienti monorene, o in cui i tumori renali sono localizzati bilateralmente. L’utilizzo di agenti emostatici ci permette di ottenere una corretta emostasi durante e successivamente la resezione del tumore. Saranno necessari studi aggiuntivi per dimostrare ulteriormente la sicurezza e l’efficacia di questo approccio e per esaminare le sue reali potenzialità in modo da offrire un reale beneficio

A Case-Control Comparison of Surgical and Functional Outcomes of Robotic-Assisted Spleen-Preserving Left Side Pancreatectomy versus Pure Laparoscopy

Aim During left-sided spleen-preserving pancreatectomy (SPLP), limitations of laparoscopy may require spleen sacrifice or conversion to maintain patient safety. The objective of our study is to compare surgical and functional outcomes of robot-assisted and pure laparoscopic SPLP in patients with benign or borderline lesions of the body/tail of the pancreas. Patients and methods This was a case-matched study: fifteen patients who had robotic SPLP (R-SPLP) were matched with 15 comparable patients who had pure laparoscopic SPLP (L-SPLP). The peri-operative variables (conversion rate, amount of bleeding, operation time, length of hospital stay, complications, mortality and readmission) as well as the spleen preservation rate were compared between the two groups, The European Organisation for Research and Treatment of Cancer QLQ-C30 (EORTC QLQ-C30) specific questionnaires were used in each arm after at least 1 year of follow up in order to evaluate quality of life (QoL). Results No R-SPLP was converted to conventional laparoscopy, hand-assisted laparoscopy, or open surgery whereas L-SPLP had a conversion rate of 13.3% (p=n.s.); also fistula formation (20% vs. 46%; p=n.s.) was higher in the laparoscopic group although not statistically significant. Mean operative time (220 vs. 279 min; p=0.027) was shorter and the spleen-preserving rate (fail/ success, 0/15 vs. 4/11; p=0.03) of R-SPLP was significantly better compared to L-SPLP. Moreover, length of hospital stay was significantly shorter in the R-SPLP group compared to the L-SPLP group (6.5 vs. 8.8 days; p=0.04). Post-operative high grade surgical complications occurred only in one L-SPLP patient (0% vs. 6.6%; p=n.s.). Quality of life scores were not significantly different between the two groups. Conclusions R-SPLP could provide an increased chance for spleen preservation and faster surgical procedure. Furthermore, fistula formation and conversion rate seem to be lower, reducing the length of the hospital stay. Our case matched study confirmed the potential peri-operative benefits of robotic assistance in this setting, however these benefits did not translate into a better quality of life at least one year post-operatively

Short-term clinical outcomes of robot-assisted intersphincteric resection and low rectal resection with double-stapling technique for cancer: a case-matched study

Background: Intersphincteric resection (ISR) with total mesorectal excision (TME) is an accepted technique for the surgical treatment of very low rectal cancer. Historically it is associated with a higher functional complication rate than the Double Stapling (DS) technique when performed with open or laparoscopic approach. The aim of this study was to compare the surgical, short-term oncologic and functional outcomes of robotic ISR TME (R-ISR-TME) with those of robotic low anterior resection TME with a double stapling technique (R-DS-TME). Methods: Between April 2010 and December 2013, 42 patients underwent robot-assisted rectal resection with TME at our General Surgery Unit, including 10 R-ISR-TME. The outcomes of the R-ISR-TME group were compared with a R-DS-TME group selected using a case-matched methodology. We evaluated the operative, pathological, short-term oncologic results and postoperative sexual, urinary and defecation functions using specific questionnaires. Results: The analyses of the data showed similar results for R-ISR-TME and R-DS-TME regarding the operative, pathological and oncologic results. Focusing on urinary and sexual function, no score values were significantly different at any time between the two groups. The daily frequency of defecation 1 year after surgery was 1.9±0.9 for RISR-TME and 1.8±0.3 for RDS-TME indicating no difference between the two groups. Moreover, there were no significant differences between the two groups in other defecation functions. The mean Wexner score 1 year after surgery was 3.0±1.1 in R-ISR-TME and 2.2±1.0 in R-DS-TME group (p=0.2) and defecation-related quality of life for R-ISR-TME and R-DS-TME was not significantly different (modified fecal incontinence quality of life score: 30.3±19.1 vs 27.5±14.5, respectively; p=0.2). Conclusions: These clinical and functional results suggest that R-ISR-TME could be a good sphincter-preserving surgery for patients with very low rectal cancer. Robotic assistance may overcome some intrinsic limitations of the ISR technique flattening the difference with the DS-TME procedure

Hand-assisted hybrid laparoscopic–robotic total proctocolectomy with ileal pouch–anal anastomosis

PURPOSE: Few studies have reported minimally invasive total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We herein report a novel hand-assisted hybrid laparoscopic-robotic technique for patients with FAP and UC. METHODS: Between February 2010 and March 2014, six patients underwent hand-assisted hybrid laparoscopic-robotic total proctocolectomy with IPAA. The abdominal colectomy was performed laparoscopically with hand assistance through a transverse suprapubic incision, also used to fashion the ileal pouch. The proctectomy was carried out with the da Vinci Surgical System. The IPAA was hand-sewn through a trans-anal approach. The procedure was complemented by a temporary diverting loop ileostomy. RESULTS: The mean hand-assisted laparoscopic surgery (HALS) time was 154.6 (±12.8) min whereas the mean robotic time was 93.6 (±8.1) min. In all cases, a nerve-sparing proctectomy was performed, and no conversion to traditional laparotomy was required. The mean postoperative hospital stay was 13.2 (±7.4) days. No anastomotic leakage was observed. To date, no autonomic neurological disorders have been observed with a mean of 5.8 (±1.3) bowel movements per day. CONCLUSIONS: The hand-assisted hybrid laparoscopic-robotic approach to total proctocolectomy with IPAA has not been previously described. Our report shows the feasibility of this hybrid approach, which surpasses most of the limitations of pure laparoscopic and robotic techniques. Further experience is necessary to refine the technique and fully assess its potential advantages

Sexual and urinary functions after robot-assisted versus pure laparoscopic total mesorectal excision for rectal cancer

Background Laparoscopic total mesorectal excision (LapTME) is a validated technique for the treatment of rectal cancer. However, the ergonomic limitations of pure laparoscopy could lead to high conversion rates and a high rate of autonomic disorders. For these reasons the robot-assisted TME (RobTME) has been proposed to overcome the limitations of LapTME. The aim of this study is to compare surgical outcomes, medium-term oncologic results, and postoperative autonomic function of LapTME versus RobTME, in a single surgeon experience. Patients and Methods The first 26 LapTME were compared with the first 26 RobTME performed by a single surgeon between January 2009 and May 2013. Perioperative outcomes were prospectively collected and compared. The impact of minimally invasive TME on autonomic function and quality of life (QOL) was analyzed with the ICIQ-FLUTS and the ICIQ-MLUTS (International Consultation on Incontinence–Male/Female Lower Urinary Tract Symptoms) and IIEF (International Index of Erectile Function)/FSFI (Female Sexual Function Index) questionnaires. Pathological aspects and oncological outcomes were also collected. Results Of the 26 LapTME, 22 were anterior resections (ARR), 2 intersphincteric resections (ISR), and 2 abdominoperineal resections (APR), while of the 26 RobTME, 17 were ARR, 5 ISR, and 4 APR. Mean operative time was significantly higher (p<0.001) while conversion rate to hand-assisted or open surgery was significantly lower in the robTME group (p<0.05). There were no significant differences in sexual and urinary scores between the two groups before surgery and at 1 year after surgery. There were no differences in 3 year overall survival, disease free survival, and recurrence rate as well as the other parameters analysed. Conclusion RobTME is a safe and effective technique and the results compare favourably to the results obtained with laparoscopic procedures. It seems a promising alternative to preserve autonomic function and results in a low conversion rate even when used for more high risk procedures such as ISR or APR

Ultrasound-Guided hifu in uterine leiomyomata: First Italian experience

Purpose: Report our three years results in treatment of uterine leiomyomata with the HIFU (high-intensity focused ultrasound) technique. Material and methods: In the period between 2009 – 2012, we treated 14 women (mean age of 47 year old; range 38 – 70 year old) affected by symptomatic uterine fibroids: 4 patients were afflicted by dysmenorrhea, 10 by metrorrhagia, 1 by urinary disturbs. Leiomyomata mean diameter before the HIFU treatment was 68.8 mm (range 55 – 140 mm). All the treatments were performed under light sedation. The equipment used was JC 200 of Haifu Chong Qing Company. The fibroids were ablated using a mean power output of 218 W, for a mean total elapse time of 2598 seconds. Results: All patients tolerated the treatment well, and no severe complications were found during follow-up (24h, 1 – 3-6 – 12 – 24 months). The efficacy of therapy was judged by a clinical evaluation, contrast-enhanced ultrasound and contrast-enhanced magnetic resonance. 12 months after the treatment no patient was still affected by dysmenorrhea and urinary disturbs, 50% had yet metrorrhagia. After treatment, non-enhanced necrotic regions were shown in all treated fibroids and the mean diameter was 49 mm (range 19 – 76 mm), with a mean decrease of 29%. Conclusion: HIFU may be a safe and effective non-invasive method to treat adenomyosis. Results are promising (symptoms reduction, volume reduction, presence of necrosis), however a larger sample is require

RESEZIONE ROBOTICA DEL RETTO CON TME PER ADENOCARCINOMA

RESEZIONE ROBOTICA DEL RETTO CON TME PER ADENOCARCINOM

ROBOTIC EXCISION OF INTERPORTO-INTERAORTOCAVAL GANGLIONEUROMA

ROBOTIC EXCISION OF INTERPORTO-INTERAORTOCAVAL GANGLIONEUROM

Diaphragmatic endometriosis: Review of the literature and first case of robot-assisted laparoscopic treatment

Background Thoracic endometriosis is a rare disorder affecting women in reproductive age. The etiopathogenesis of this disease is not well understood. The symptoms appear, but not necessarily, during periods in person affected by the condition. Methods A 35-year-old woman came to our clinic, the Infertility and Assisted Reproduction Center of the University of Pisa, for infertility treatment. She described a clinical history of abdominal pain with irradiation up to the right shoulder, depending on her breathing or position, during menstruation. She also reported that she did not experience these symptoms while taking an oral contraceptive. Pelvic ultrasound examination and thorax X-ray were normal. The patient also underwent thoracic and abdominal pelvis magnetic resonance imaging (MRI). Thoracic MRI revealed a nodule on the right hemidiaphragm. It was decided to perform surgical removal of the nodule. Robotic-assisted surgery was used because of its multiple advantages in comparison with laparoscopic surgery, such as a 3-dimensional view, a decrease in surgeon fatigue and tremors, and an increase of wrist motion with improved dexterity and greater surgical precision. The surgery was performed in May 2012. The patient was put on the left lateral bedside. Pneumoperitoneum with CO2 was established with an intra-abdominal pressure of 12 mm Hg using a Veress needle. Robotic trocars of 8-mm diameter were introduced at the diaphragmatic level and connected to the robot arms. Her pelvic and abdominal organs appeared healthy. The right hemidiaphragm presented adherence with the liver due to endometriosis disease. We removed the adhesion, and we performed the excision of the diaphragmatic endometriotic nodule. The nodule was extracted through an endobag. Operative time lasted 2 hours. Conclusions The postoperative evolution was satisfactory, and the patient left the hospital on the third postoperative day. No complications occurred. We showed that this approach is feasible and safe, without conversion to laparotomy

ROBOT ASSISTED ADRENALECTOMY

ROBOT ASSISTED ADRENALECTOM