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895 A NOVEL UPSIDE ADDUCTED ARM (UAA) POSITIONING FOR ROBOTIC-ASSISTED TRANSPERITONEAL UPPER TRACT SURGERY TO ELIMINATE ROBOTIC ARM INTERFERENCE
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THE JOURNAL OF UROLOGY姞
895 A NOVEL UPSIDE ADDUCTED ARM (UAA) POSITIONING FOR ROBOTIC-ASSISTED TRANSPERITONEAL UPPER TRACT SURGERY TO ELIMINATE ROBOTIC ARM INTERFERENCE Hani Rashid, Angelo Cambio*, Guan Wu, Rochester, NY INTRODUCTION AND OBJECTIVES: For robotic-assisted laparoscopic transperitoneal renal surgery, the patient is usually positioned in modified lateral decubitus position slightly flexed at the flank region with the downside arm on a padded arm board. The upside arm is directed outward in front of the patient by an arm board or padded support. During surgery, this positioning leads to frequent collisions between the robotic arm and the upside arm, resulting in maneuver limitation. To solve this problem, we propose a novel upside arm position, called upside arm adducted (UAA) positioning. METHODS: Instead of positioning the upside arm of the patient forward on an arm board, we positioned the upside arm adducted along the side of the patient’s body and slightly toward to the patient’s back. The arm was supported with rolls, egg crates and secured with tape [Figure 1]. This new positioning was tested on multiple robotic-assisted laparoscopic transperitoneal upper tract surgeries. RESULTS: From June 2008 to October 2009, we used UAA positioning for a total of 91 robotic cases: 49 partial nephrectomies, 23 pyeloplasties, 12 nephroureterectomies with bladder cuff, 4 radical nephrectomies, and 3 adrenalectomies. This novel positioning was easy to set up and eliminated the upside arm interference which occurs with conventional positioning. There were no cases of neurologic deficits or musculoskeletal injuries. During 10 of 12 nephroureterectomies, the UAA positioning allowed for robotic access to the pelvis without repositioning the patient for the distal ureterectomy and bladder cuff portion of the surgery, leading to decreased surgical time. CONCLUSIONS: This novel UAA positioning for robotic assisted laparoscopic transperitoneal upper tract surgery decreases robotic arm-patient arm interference, provides additional working space for the assistant help or for placement of a fourth robotic arm in the upper abdomen, and offers the ability to perform robotic nephroureterectomies without repositioning the patient for the distal ureter and bladder cuff portion of the procedure. We propose that this should become the standard positioning for all robotic and laparoscopic upper tract surgeries.
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
Patients were stratified into 2 groups: 55 patients with tumors ⬎ 4 cm on preoperative imaging (Group 1) and 227 patients with tumors ⬍ or ⫽ 4 cm (Group 2). Preoperative outcomes were compared between groups. Chi-square and student T tests were used for categorical and continuous variables respectively. A p-value ⬍ 0.05 was considered statistically significant. RESULTS: Mean radiographic tumor size was 5.4 cm (4-8.5 cm) for Group 1 and 2.3 cm (0.7-3.9 cm) for Group 2. No significant differences were found in total operative time (223 vs. 207 min), warm ischemia time (27 vs. 20 min), estimated blood loss (260 vs. 217 ml), length of hospital stay, complication rates, and change in estimated creatinine clearance in Group 1 and Group 2, respectively (Table 1). There were 5 focal microscopic positive margins in Group 2 (2.2%) of which 2 patients had undergone enucleation for angiomyolipoma, resulting in an overall positive margin rate of 1.3 % for malignancy. There was upstaging to pT3 in 3 (5.4%) patients in Group 1 and in 7 (3.1%) patients in Group 2. Mean follow-up was 6.5 mon (1-28) in Group 1 and 7.7 mon (0.2-36) in Group 2 respectively. There was 1 local recurrence in Group 1 in a patient with high grade T3a disease and negative margins who underwent completion nephrectomy with no evidence of the disease at 1 year follow up. CONCLUSIONS: In the largest multi-institutional series of RPN for clinical stage T1b tumors to date, RPN for tumors ⬎ 4 cm is safe and feasible showing comparable outcomes to RPN for smaller tumors. There was a trend towards longer warm ischemia times with large tumors that did not achieve statistical significance. Future studies with extended follow-up are necessary to further determine the role of RPN for large tumors. Table 1 Patients Variable and Perioperative Outcomes for Robotic Partial Nephrectomy for Renal Tumors Greater than 4 cm Group 2 Group 1 (n⫽227) (n⫽55) (ⱕ 4cm) p-value (⬎ 4 cm) Variables Mean Age, years, (SD) * 62 (12) 61 (12) 0.54 BMI, kg/m2,
32 (7)
30 (6)
0.18
Upper Pole
15 (27.3)
56 (25.2)
0.13
Mid Pole
25 (45.5)
98 (44.1)
0.02
Lower Pole
15 (27.3)
68 (30.6)
0.36
Endophytic2
14 (25.5)
52 (23.2)
0.17
Exophytic
28 (51)
108 (48.2)
0.21
Mesophytic
13 (23.6)
64 (28.6)
0.57
Location, n, (%)1
OR Time, min Ischemia Time, min EBL, ml Collecting System Repair, n (%)3 Length of stay, days % Change in Postop day 3 eGFR**
Source of Funding: None
Positive Margins Follow-up, months
223 (58)
207 (61)
0.08
27 (8)
20 (9)
4.3
260 (226)
217 (223)
0.21
32 (72.7)
79 (45.7)
3.03
3.2 (2) 39% (2.1) 0 (0) 6.5 (7.7)
3 (2) 42% (2.5) 5 (2.2%) 7.7 (8.3)
0.28 0.96 0.54 0.42
Complications, n(%)
896
Urine leak
3 (5.4)
2 (0.88)
ROBOTIC PARTIAL NEPHRECTOMY FOR RENAL TUMORS GREATER THAN 4 CM: A MULTI-INSTITUTIONAL ANALYSIS OF PERIOPERATIVE OUTCOMES IN 282 PATIENTS.
Bleeding
2 (3.6)
6 (2.6)
0.06
PE/DVT
0 (0)
3 (1.3)
0.12
Firas Petros*, Detroit, MI; Michael Stifelman, Lori Dulabon, New York, NY; Georges-Pascal Haber, Jihad Kaouk, Cleveland, OH; Craig Rogers, Detroit, MI INTRODUCTION AND OBJECTIVES: Minimally invasive partial nephrectomy is most commonly performed for renal tumors less than 4 cm. Robotic partial nephrectomy (RPN) for tumors greater than 4 cm has not been assessed. We evaluate perioperative outcomes of RPN for tumors greater than 4 cm in size compared to RPN for tumors less than 4 cm. METHODS: Data for 282 consecutive patients who underwent RPN at 3 institutions between June 2006-October 2009 were reviewed.
1.74
* All continuous values are expressed as mean and SD **eGFR⫽Estimated Creatinine Clearance 1 Data available for 222 patients in group 2. 2 Data available for 224 patients in Group 2. 3 Data available for 44 patients in Group 1 and 173 patients in group 2.
Source of Funding: None
THE JOURNAL OF UROLOGY姞
895 A NOVEL UPSIDE ADDUCTED ARM (UAA) POSITIONING FOR ROBOTIC-ASSISTED TRANSPERITONEAL UPPER TRACT SURGERY TO ELIMINATE ROBOTIC ARM INTERFERENCE Hani Rashid, Angelo Cambio*, Guan Wu, Rochester, NY INTRODUCTION AND OBJECTIVES: For robotic-assisted laparoscopic transperitoneal renal surgery, the patient is usually positioned in modified lateral decubitus position slightly flexed at the flank region with the downside arm on a padded arm board. The upside arm is directed outward in front of the patient by an arm board or padded support. During surgery, this positioning leads to frequent collisions between the robotic arm and the upside arm, resulting in maneuver limitation. To solve this problem, we propose a novel upside arm position, called upside arm adducted (UAA) positioning. METHODS: Instead of positioning the upside arm of the patient forward on an arm board, we positioned the upside arm adducted along the side of the patient’s body and slightly toward to the patient’s back. The arm was supported with rolls, egg crates and secured with tape [Figure 1]. This new positioning was tested on multiple robotic-assisted laparoscopic transperitoneal upper tract surgeries. RESULTS: From June 2008 to October 2009, we used UAA positioning for a total of 91 robotic cases: 49 partial nephrectomies, 23 pyeloplasties, 12 nephroureterectomies with bladder cuff, 4 radical nephrectomies, and 3 adrenalectomies. This novel positioning was easy to set up and eliminated the upside arm interference which occurs with conventional positioning. There were no cases of neurologic deficits or musculoskeletal injuries. During 10 of 12 nephroureterectomies, the UAA positioning allowed for robotic access to the pelvis without repositioning the patient for the distal ureterectomy and bladder cuff portion of the surgery, leading to decreased surgical time. CONCLUSIONS: This novel UAA positioning for robotic assisted laparoscopic transperitoneal upper tract surgery decreases robotic arm-patient arm interference, provides additional working space for the assistant help or for placement of a fourth robotic arm in the upper abdomen, and offers the ability to perform robotic nephroureterectomies without repositioning the patient for the distal ureter and bladder cuff portion of the procedure. We propose that this should become the standard positioning for all robotic and laparoscopic upper tract surgeries.
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
Patients were stratified into 2 groups: 55 patients with tumors ⬎ 4 cm on preoperative imaging (Group 1) and 227 patients with tumors ⬍ or ⫽ 4 cm (Group 2). Preoperative outcomes were compared between groups. Chi-square and student T tests were used for categorical and continuous variables respectively. A p-value ⬍ 0.05 was considered statistically significant. RESULTS: Mean radiographic tumor size was 5.4 cm (4-8.5 cm) for Group 1 and 2.3 cm (0.7-3.9 cm) for Group 2. No significant differences were found in total operative time (223 vs. 207 min), warm ischemia time (27 vs. 20 min), estimated blood loss (260 vs. 217 ml), length of hospital stay, complication rates, and change in estimated creatinine clearance in Group 1 and Group 2, respectively (Table 1). There were 5 focal microscopic positive margins in Group 2 (2.2%) of which 2 patients had undergone enucleation for angiomyolipoma, resulting in an overall positive margin rate of 1.3 % for malignancy. There was upstaging to pT3 in 3 (5.4%) patients in Group 1 and in 7 (3.1%) patients in Group 2. Mean follow-up was 6.5 mon (1-28) in Group 1 and 7.7 mon (0.2-36) in Group 2 respectively. There was 1 local recurrence in Group 1 in a patient with high grade T3a disease and negative margins who underwent completion nephrectomy with no evidence of the disease at 1 year follow up. CONCLUSIONS: In the largest multi-institutional series of RPN for clinical stage T1b tumors to date, RPN for tumors ⬎ 4 cm is safe and feasible showing comparable outcomes to RPN for smaller tumors. There was a trend towards longer warm ischemia times with large tumors that did not achieve statistical significance. Future studies with extended follow-up are necessary to further determine the role of RPN for large tumors. Table 1 Patients Variable and Perioperative Outcomes for Robotic Partial Nephrectomy for Renal Tumors Greater than 4 cm Group 2 Group 1 (n⫽227) (n⫽55) (ⱕ 4cm) p-value (⬎ 4 cm) Variables Mean Age, years, (SD) * 62 (12) 61 (12) 0.54 BMI, kg/m2,
32 (7)
30 (6)
0.18
Upper Pole
15 (27.3)
56 (25.2)
0.13
Mid Pole
25 (45.5)
98 (44.1)
0.02
Lower Pole
15 (27.3)
68 (30.6)
0.36
Endophytic2
14 (25.5)
52 (23.2)
0.17
Exophytic
28 (51)
108 (48.2)
0.21
Mesophytic
13 (23.6)
64 (28.6)
0.57
Location, n, (%)1
OR Time, min Ischemia Time, min EBL, ml Collecting System Repair, n (%)3 Length of stay, days % Change in Postop day 3 eGFR**
Source of Funding: None
Positive Margins Follow-up, months
223 (58)
207 (61)
0.08
27 (8)
20 (9)
4.3
260 (226)
217 (223)
0.21
32 (72.7)
79 (45.7)
3.03
3.2 (2) 39% (2.1) 0 (0) 6.5 (7.7)
3 (2) 42% (2.5) 5 (2.2%) 7.7 (8.3)
0.28 0.96 0.54 0.42
Complications, n(%)
896
Urine leak
3 (5.4)
2 (0.88)
ROBOTIC PARTIAL NEPHRECTOMY FOR RENAL TUMORS GREATER THAN 4 CM: A MULTI-INSTITUTIONAL ANALYSIS OF PERIOPERATIVE OUTCOMES IN 282 PATIENTS.
Bleeding
2 (3.6)
6 (2.6)
0.06
PE/DVT
0 (0)
3 (1.3)
0.12
Firas Petros*, Detroit, MI; Michael Stifelman, Lori Dulabon, New York, NY; Georges-Pascal Haber, Jihad Kaouk, Cleveland, OH; Craig Rogers, Detroit, MI INTRODUCTION AND OBJECTIVES: Minimally invasive partial nephrectomy is most commonly performed for renal tumors less than 4 cm. Robotic partial nephrectomy (RPN) for tumors greater than 4 cm has not been assessed. We evaluate perioperative outcomes of RPN for tumors greater than 4 cm in size compared to RPN for tumors less than 4 cm. METHODS: Data for 282 consecutive patients who underwent RPN at 3 institutions between June 2006-October 2009 were reviewed.
1.74
* All continuous values are expressed as mean and SD **eGFR⫽Estimated Creatinine Clearance 1 Data available for 222 patients in group 2. 2 Data available for 224 patients in Group 2. 3 Data available for 44 patients in Group 1 and 173 patients in group 2.
Source of Funding: None