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90 Laparoscopic robotic assisted retroperitoneal lymphadenctomy in paratesticular rhabdomyosarcoma
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videos / european urology supplements 10 (2011) 557–566
done. With the trocars in the current position, the seminal vesicles were first dissected. Then the anterior plane of the bladder identified. Careful dissection of the prostate and surrounding tissues was performed. The bladder neck was incised and then it was very easy to identify the previous section with the Collins knife and to complete the separation of the bladder from the prostate. Then, since the lateral attachments of the prostate facilitates the exposure, we performed a suture with simple stitches of the bladder neck in order to facilitate the bladder and urethra anastomosis later on. Then we proceeded with the radical prostatectomy as usual. Results: Blood loss of 200 cc. The recovery was uneventful and the patient was discharged on day two. The pathology showed an multifocal adenocarcinoma of the prostate Gleason 3+4, mainly in the left lateral lobe with periprostatic tissue and seminal vesicles with no tumor, margin negative posteriorly and at the bladder neck, Stage pT2c. At one year follow up the patient is continent and with undetectable PSA. Conclusions: Radical prostatectomy is an established procedure but sometimes previous surgeries may give some more technical difficulties and even worsen the oncological results (margins). The endoscopic approach improves the confidence of the surgeon in the identification of the ureteral meatus and the incision of the bladder neck, without jeopardizing oncological results. 90 Laparoscopic robotic assisted retroperitoneal lymphadenctomy in paratesticular rhabdomyosarcoma J. Palou1 , L. Gausa1 , G. Urdaneta1 . 1 Fundaci´ o Puigvert, Barcelona, Spain Introduction: Retroperitoneal lymph node dissection is one of the steps in the management of testicular cancer. There is controversy as a staging/curative procedure in localized disease of the testis. Paratesticular tumours are very rare but when sarcoma is present, these are aggressive and metastatizing tumours. Objective: To show the feasibility of robotic assisted retroperitoneal lymphadenectomy as a staging procedure in a patient with persistence of disease in the scrotum after systemic treatment. Material and Methods: A 17 year old man had been treated in another center of excision of a right paratesticular mass with a pathology of rhabdomyosarcoma with positive margins. He received three cycles of chemotherapy (Adriamicyn, Ifosfamide, Vincristine) and then was sent to our center. Body CT scan and bone scan were negative. Local excision of the testis and retroperitoneal robotic assisted lymphadenectomy was planned. The patient was positioned with right lateral position and four trocars were placed (one for the optics, two for the robot and one for the assistant). The dissection was started with the excision of the paracaval nodes from the external iliac artery to the renal vessels. Then we proceeded with the anterior and interaortocaval nodes. The retroperitoneal spermatic cord was completely excised. Results: The blood loss was negligible. The recovery was uneventful. The patient was discharged on day three. The pathology showed a mass of 13×3 mm paratesticular rhabdomyosarcoma with negative margins and no tumour in the retroperitoneal dissection (16 nodes). The patient received three more cycles of chemotherapy and local radiotherapy. Conclusions: Retroperitoneal robotic assisted lymphadenectomy is a feasible and available technique for those who are used to robotic surgery. The possibility to have access to a close view and dissection of the retroperitoneal structures facilitates its feasibility.
91 Robotic assisted uretero–ureteral (donor–receiver) anastomosis J. Hauser1 , S. Tran1 , J. Schwartz1 . 1 University Hospital Geneva, Switzerland Recurrent kidney graft ureteral strictures are significant challenges that may lead to perform a uretero–ureteral (donor– receiver) anastomosis classically performed through an open surgical access. Because of the suture difficulties related to this reconstructive process, and also because of the location of the operative site, no laparoscopic attempts have been reported as yet. The da Vinci robot enables now to render this operation minimally invasive, as shown in the 2 cases presented in this video. Such a minimally invasive solution is welcomed in patients having gone through the invasive process of a kidney graft. 92 Management of difficult anatomy during bladder neck dissection while performing robot assisted radical prostatectomy: the median lobe S. Chauhan1 , R.F. Coelho1 , O. Schatloff1 , R. Valero1 , A. Sivaraman1 , Y.H. Ko1 , J. Syed1 , K.J. Palmer1 , V.R. Patel1 . 1 Global Robotics Institute; Florida Hospital-Celebration Health, USA Purpose: To determine whether the presence of median lobe affects perioperative outcomes, positive surgical margin (PSM) rates and short-term urinary continence outcomes after Robot-Assisted Radical Prostatectomy (RARP) performed by an experienced surgeon. Methods: We analyzed prospectively 1,693 consecutive patients who underwent RARP for treatment of clinically localized prostate cancer. All the procedures were performed by a single surgeon (VRP). Patients were categorized in two groups based on the presence or absence of a median lobe identified during RARP. Outcomes analyzed included operative time, Estimated Blood Loss (EBL), nerve-sparing procedure, overall complication rates, length of hospital stay, days with catheter, presence of anastomotic leakage on cystogram, number of bladder neck reconstruction procedures, tumor volume, pathological stage, PSM rates, pathological Gleason score and continence rates. Continence was defined as the use of “no pads” based on the patient responses to the EPIC (Expanded Prostate Cancer Index Composite) questions at 1, 4, 6, 12 and 24 weeks after catheter removal. Results: A median lobe was intra-operatively identified in 323 (19%) patients. Patients with median lobes were slightly older (median 63 vs. 60 years, p < 0.001), had higher PSA levels (median 5.7 vs. 4.7 ng/ml, P < 0.001) and higher AUASS before RARP (10 vs. 6, p < 0.001). The number of bladder neck reconstruction procedures (93.5% vs. 65.7%, p < 0.001) and the median prostate weight (64 vs. 46 g, p < 0.001) were also higher in the median lobe group. Both groups had equivalent EBL, length of hospital stay, mean number of days with catheter, pathological stage, pathological Gleason score, number of nerve sparing procedures, overall complication rates, number of anastomotic leakages, mean tumor volume, overall PSM rates and PSM rate at the bladder neck. The median overall operative time was slightly greater in patients with median lobe (80 vs. 75 minutes, p < 0.001). However, there was no difference in the operative time between the two groups when stratifying this result by prostate weight. Continence rates were also equivalent between patients with and without median lobe at 1 week (27.8% vs. 27%, p = 0.870), 4 weeks (42.3% vs. 48%, p = 0.136), 6 weeks (64.1% vs. 69.5%, p = 0.126), 12 weeks (82.5% vs. 86.8%, p = 0.107) and 24 weeks (91.5% vs. 94.1%, p = 0.183) after catheter removal. Finally, the median time to recovery of continence was similar between the groups in
videos / european urology supplements 10 (2011) 557–566
done. With the trocars in the current position, the seminal vesicles were first dissected. Then the anterior plane of the bladder identified. Careful dissection of the prostate and surrounding tissues was performed. The bladder neck was incised and then it was very easy to identify the previous section with the Collins knife and to complete the separation of the bladder from the prostate. Then, since the lateral attachments of the prostate facilitates the exposure, we performed a suture with simple stitches of the bladder neck in order to facilitate the bladder and urethra anastomosis later on. Then we proceeded with the radical prostatectomy as usual. Results: Blood loss of 200 cc. The recovery was uneventful and the patient was discharged on day two. The pathology showed an multifocal adenocarcinoma of the prostate Gleason 3+4, mainly in the left lateral lobe with periprostatic tissue and seminal vesicles with no tumor, margin negative posteriorly and at the bladder neck, Stage pT2c. At one year follow up the patient is continent and with undetectable PSA. Conclusions: Radical prostatectomy is an established procedure but sometimes previous surgeries may give some more technical difficulties and even worsen the oncological results (margins). The endoscopic approach improves the confidence of the surgeon in the identification of the ureteral meatus and the incision of the bladder neck, without jeopardizing oncological results. 90 Laparoscopic robotic assisted retroperitoneal lymphadenctomy in paratesticular rhabdomyosarcoma J. Palou1 , L. Gausa1 , G. Urdaneta1 . 1 Fundaci´ o Puigvert, Barcelona, Spain Introduction: Retroperitoneal lymph node dissection is one of the steps in the management of testicular cancer. There is controversy as a staging/curative procedure in localized disease of the testis. Paratesticular tumours are very rare but when sarcoma is present, these are aggressive and metastatizing tumours. Objective: To show the feasibility of robotic assisted retroperitoneal lymphadenectomy as a staging procedure in a patient with persistence of disease in the scrotum after systemic treatment. Material and Methods: A 17 year old man had been treated in another center of excision of a right paratesticular mass with a pathology of rhabdomyosarcoma with positive margins. He received three cycles of chemotherapy (Adriamicyn, Ifosfamide, Vincristine) and then was sent to our center. Body CT scan and bone scan were negative. Local excision of the testis and retroperitoneal robotic assisted lymphadenectomy was planned. The patient was positioned with right lateral position and four trocars were placed (one for the optics, two for the robot and one for the assistant). The dissection was started with the excision of the paracaval nodes from the external iliac artery to the renal vessels. Then we proceeded with the anterior and interaortocaval nodes. The retroperitoneal spermatic cord was completely excised. Results: The blood loss was negligible. The recovery was uneventful. The patient was discharged on day three. The pathology showed a mass of 13×3 mm paratesticular rhabdomyosarcoma with negative margins and no tumour in the retroperitoneal dissection (16 nodes). The patient received three more cycles of chemotherapy and local radiotherapy. Conclusions: Retroperitoneal robotic assisted lymphadenectomy is a feasible and available technique for those who are used to robotic surgery. The possibility to have access to a close view and dissection of the retroperitoneal structures facilitates its feasibility.
91 Robotic assisted uretero–ureteral (donor–receiver) anastomosis J. Hauser1 , S. Tran1 , J. Schwartz1 . 1 University Hospital Geneva, Switzerland Recurrent kidney graft ureteral strictures are significant challenges that may lead to perform a uretero–ureteral (donor– receiver) anastomosis classically performed through an open surgical access. Because of the suture difficulties related to this reconstructive process, and also because of the location of the operative site, no laparoscopic attempts have been reported as yet. The da Vinci robot enables now to render this operation minimally invasive, as shown in the 2 cases presented in this video. Such a minimally invasive solution is welcomed in patients having gone through the invasive process of a kidney graft. 92 Management of difficult anatomy during bladder neck dissection while performing robot assisted radical prostatectomy: the median lobe S. Chauhan1 , R.F. Coelho1 , O. Schatloff1 , R. Valero1 , A. Sivaraman1 , Y.H. Ko1 , J. Syed1 , K.J. Palmer1 , V.R. Patel1 . 1 Global Robotics Institute; Florida Hospital-Celebration Health, USA Purpose: To determine whether the presence of median lobe affects perioperative outcomes, positive surgical margin (PSM) rates and short-term urinary continence outcomes after Robot-Assisted Radical Prostatectomy (RARP) performed by an experienced surgeon. Methods: We analyzed prospectively 1,693 consecutive patients who underwent RARP for treatment of clinically localized prostate cancer. All the procedures were performed by a single surgeon (VRP). Patients were categorized in two groups based on the presence or absence of a median lobe identified during RARP. Outcomes analyzed included operative time, Estimated Blood Loss (EBL), nerve-sparing procedure, overall complication rates, length of hospital stay, days with catheter, presence of anastomotic leakage on cystogram, number of bladder neck reconstruction procedures, tumor volume, pathological stage, PSM rates, pathological Gleason score and continence rates. Continence was defined as the use of “no pads” based on the patient responses to the EPIC (Expanded Prostate Cancer Index Composite) questions at 1, 4, 6, 12 and 24 weeks after catheter removal. Results: A median lobe was intra-operatively identified in 323 (19%) patients. Patients with median lobes were slightly older (median 63 vs. 60 years, p < 0.001), had higher PSA levels (median 5.7 vs. 4.7 ng/ml, P < 0.001) and higher AUASS before RARP (10 vs. 6, p < 0.001). The number of bladder neck reconstruction procedures (93.5% vs. 65.7%, p < 0.001) and the median prostate weight (64 vs. 46 g, p < 0.001) were also higher in the median lobe group. Both groups had equivalent EBL, length of hospital stay, mean number of days with catheter, pathological stage, pathological Gleason score, number of nerve sparing procedures, overall complication rates, number of anastomotic leakages, mean tumor volume, overall PSM rates and PSM rate at the bladder neck. The median overall operative time was slightly greater in patients with median lobe (80 vs. 75 minutes, p < 0.001). However, there was no difference in the operative time between the two groups when stratifying this result by prostate weight. Continence rates were also equivalent between patients with and without median lobe at 1 week (27.8% vs. 27%, p = 0.870), 4 weeks (42.3% vs. 48%, p = 0.136), 6 weeks (64.1% vs. 69.5%, p = 0.126), 12 weeks (82.5% vs. 86.8%, p = 0.107) and 24 weeks (91.5% vs. 94.1%, p = 0.183) after catheter removal. Finally, the median time to recovery of continence was similar between the groups in