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937 PERI-OPERATIVE OUTCOMES AND EARLY COMPLICATION RATES AFTER 4000 ROBOT ASSISTED RADICAL PROSTATECTOMIES
Vol. 185, No. 4S, Supplement, Monday, May 16, 2011
935 SINGLE ACADEMIC INSTITUTION EXPERIENCE IN APPLICATION OF LAPAROENDOSCOPIC SINGLE-SITE SURGERY IN ADULT AND PEDIATRIC UROLOGIC SURGERY Seth Cohen*, George Chiang, Marvalyn DeCambre, Jonathan Silberstein, Sean Stroup, Jeffrey Woldrich, Wassim Bazzi, Ithaar Derweesh, San Diego, CA INTRODUCTION AND OBJECTIVES: Adoption of Laparoendoscopic Single-site surgery (LESS) into pediatric surgical practice represents a further development of the minimally invasive surgical armamentarium for pediatric urology. The extension of LESS has been undertaken in partnership between the adult and pediatric urologic surgeons at the University of California, San Diego. METHODS: Adult LESS (A-LESS) commenced in 1/2009, followed by initiation of Pediatric LESS (P-LESS) in 11/2009. Prior to initiation of P-LESS, pediatric urology faculty (GS, MD) proceeded with LESS-modified Society of American Gastrointestinal and Endoscopic Surgeons/Fundamentals of Laparoscopic Surgery curriculum emphasizing didactics, dry simulation drills, and preclinical live experience in partnership with the adult urologic surgeon (IHD). A-LESS were performed by transperitoneal (40) and retroperitoneal approach (20). Most (52) were performed by a single site approach with multiple trocars. All P-LESS were performed by transperitoneal SILS port (Covidien, Mansfield, MA, USA). Patient demographics, intraoperative parameters, outcomes, and complications were recorded. RESULTS: 60 A-LESS and 15 P-LESS have been performed. A-LESS included 29 radical and 17 partial nephrectomies, 6 nephrectomies with renal vein thrombectomies, and 7 adrenalectomies. P-LESS included 7 unilateral and 4 bilateral nephrectomies, 1 ureteral reimplant, 1 varicocelectomy, and 2 orchidopexies. One adult case each required conversion to open, multiport laparoscopy, or placement of second trocar at separate site. One P-LESS converted to open surgery. Median age (years, range) for A-LESS was 62.5 (24 – 85.6), and for P-LESS was 6 (1.2–17.9 years). Median hospital stay (hours) for A-LESS was 60, and for P-LESS was 51.6. Median operative times (minutes, range) for A- and P-LESS were 154 (35–220) and 183 (58 –564). Median estimated blood loss (mL, range) for A-LESS was 100 (5–500) and for P-LESS was 10 (0 –100). Median discharge pain score for A-LESS (visual analog scale, range) was 1 (0 – 4); median pain score (Faces, Legs, Activity, Cry Consolability scale, range) on post-operative day 1 for P-LESS was 2.2 (0 – 4.4). Complications were noted in 4 (6.7%) A-LESS and 0 P-LESS. CONCLUSIONS: Adaptation of LESS technique with excellent, reproducible and comparable outcomes was achieved by collaboration between adult and pediatric urologic surgeons. Further investigation is requisite to determine ultimate utility of LESS in adult and pediatric urology. Source of Funding: None
936 IS ROBOTIC ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY FINANCIALLY WORTHWHILE? Sammy Elsamra*, Andrew Leone, Michael Lasser, Simone Thavaseelan, George Haleblian, Gyan Pareek, Providence, RI INTRODUCTION AND OBJECTIVES: Robotic assisted laparoscopic partial nephrectomy (RALPN) is emerging as an alternative to laparoscopic partial nephrectomy for the surgical management of small renal masses. While, many studies may tout the benefits of RALPN, none have evaluated the financial cost of this approach. Herein, we evaluate the financial cost of RALPN as compared to hand-assisted laparoscopic partial nephrectomy (HALPN) at our institution. METHODS: All HALPN and RALPN from 2006 to 2010 were reviewed for patient age, size of tumor, operative times, and length of stay (LOS). Total cost of each procedure was based on operative room cost (time cost of room, anesthesia time cost, and supply) and hospital stay cost. Cost for common items (drapes, floseal, laparty, etc) and unique items (gel-port & harmonic for HALPN and robotic instrument arms for RALPN) was tabulated. These costs were applied to the mean HALPN and RALPN patient. Student’s t-test was utilized.
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RESULTS: Of 100 minimally invasive partial nephrectomies (2006 –2010), 69 patients who fit study criteria were evaluated. 47 patients underwent HALPN and 21 patients underwent RALPN. The two groups were found to have similar age and tumor size. Room time and operative time were significantly shorter for the HALPN cohort (p⫽0.001) whereas LOS was significantly shorter in the RALPN cohort (p⫽0.019). In table 1 overall RALPN costs were $1,495 more than HALPN (HALPN-$7,917, RALPN-$9,409). While, the decreased LOS led to a cost savings of $228 for the RALPN cohort, the increased time in the OR led to an increased cost of $1225 (OR time fee and anesthesia fee). Further, the cost of surgical supplies was $495 greater for the RALPN. Medicare re-imbursement rates for the urologist were not included as the same billing codes are applied for both procedures. CONCLUSIONS: Our data reveals that while LOS is significantly shorter for RALPN, operative and room times were significantly greater. The cost advantage associated with decreased length of stay for RALPN did not recover the greater financial cost associated with increased surgery time, OR time, and robotic equipment. Given the current status of our healthcare system and the economy, one must consider the financial implications of new technology and whether this financial cost is met with real patient benefit.
Source of Funding: None
937 PERI-OPERATIVE OUTCOMES AND EARLY COMPLICATION RATES AFTER 4000 ROBOT ASSISTED RADICAL PROSTATECTOMIES Sanket Chauhan*, Rafael Coelho, Ananthakrishnan Sivaraman, Kenneth Palmer, Bernardo Rocco, Vipul Patel, Celebration, FL INTRODUCTION AND OBJECTIVES: Robot Assisted Radical Prostatectomy (RARP) is a rapidly evolving minimally invasive treatment modality for clinically localized prostate cancer. We report single surgeon experience with 4000 consecutive cases analyzing the perioperative outcomes and early complications. METHODS: After IRB approval, we retrospectively analyzed 4000 consecutive cases of RARP. All cases were performed via a 6 port trans-peritoneal technique. The complications were classified according to the Clavien grading system. RESULTS: Patient demographics are listed in Table 1. The median (IQR) OR time and blood loss were respectively 75 min (75– 80) and 100 ml (100 –150) while the median length of hospital stay and days on catheter were 1 day (1–1) and 5 days (4 – 6) respectively. The overall positive margin rate was 11.1% (pT2: 5.8%, pT3: 27.1%, pT4: 51.6%). Overall, 224 patients had 246 complications (6.1%). The most common peri-operative complication was ileus (0.7%) followed by bleeding requiring blood transfusions (0.5%). Intra-operatively, two patients (0.05%) had rectal injury while one patient (0.03%) had a small bowel injury during lysis of adhesions by general surgery. Two surgeries had to be converted laparoscopically due to system malfunction. The most common post operative complication was anastomosis leak (1.9%) followed by acute urinary retention (0.63%) [Table 2].
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The incidence of minor complications (Clavien 1⫹2) was 5.1%, while that of major complications (Clavien grade 3⫹4) was 0.95%. Two patients (0.05%) died within 90 days of surgery, both unrelated to the robotic procedure: one had a cavernous sinus thrombosis, while the other had a post-operative myocardial infarction. CONCLUSIONS: After a decade of evolution, mature series reporting the outcomes of RARP are now available. These can be used to counsel the patients while explaining the peri-operative outcomes and complications of RARP.
Vol. 185, No. 4S, Supplement, Monday, May 16, 2011
938 NEEDLE STEERING SYSTEM USING DUTY-CYCLED ROTATION FOR PERCUTANEOUS KIDNEY ACCESS Khaled Shahrour*, Michael Ost, Nathan Wood, Stephen Jackman, Timothy Averch, Cameron Riviere, Pittsburgh, PA INTRODUCTION AND OBJECTIVES: A novel technique of percutaneous renal access (PRA) is needed to overcome the drawbacks of using rigid needles. If a flexible needle with a beveled tip is inserted into tissue, it will bend in the direction of the tip. The curve depends on the needle flexibility and tissue resistance. If the needle spins constantly during insertion, it follows a straight path as the bevel is negated. Alternating periods of spinning and stopping (duty-cycling) allows for proportional control of the trajectory in order to steer the needle in tissue non-traumatically. Our objective is to test the ability of the duty-cycled steerable needle system to follow a specific trajectory in vitro using phantom and swine kidneys. METHODS: The nitinol needle has a 0.52mm diameter with a 7° bevel and is attached to a motor for inserting motion and to another motor for spinning. The system is controlled using a graphical user interface to automatically select tip orientation, insertion and spinning speeds based on the actual needle position. A PRA phantom kidney training model was used in which the minor calyces were set as target points and needle is followed in real-time by a camera. In swine experiments, needle is followed fluoroscopically into the contrast-filled calyces. The distance between the actual path of the needle and the planned path (cross track error) and the final needle position were the objective and subjective outcomes respectively. RESULTS: The needle successfully entered the phantom and swine kidneys during all attempts. Mean cross track error was 0.71mm with a range between 0.05mm and 1.4mm in phantoms. In swine kidneys, the mean cross track error was 1.38 mm. CONCLUSIONS: Duty-cycled needle can be successfully steered along a pre-planed path in vitro and in swine kidney. Further studies on cadaveric and live animals are warranted prior to clinical investigation.
Source of Funding: None
939 USE OF ROBOTIC ASSISTED RADICAL CYSTECTOMY VERSUS OPEN RADICAL CYSTECTOMY FOR BLADDER CANCER IS ASSOCIATED WITH DECREASED BLOOD LOSS AND PERIOPERATIVE TRANSFUSION RATE Stephen Kappa*, Nashville, TN; Shady Salem, Shebin El-Koom, Egypt; Sam Chang, Peter Clark, Michael Cookson, Rodney Davis, David Penson, Roxy Baumgartner, Chad You, Joseph Smith, Daniel Barocas, Nashville, TN
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Blood loss and perioperative transfusions are important markers of clinical outcomes after radical cystectomy for bladder cancer. We compared Robotic Assisted Radical Cystectomy (RARC) versus Open Radical Cystectomy (ORC) to determine the effect of surgical approach on blood loss and perioperative transfusion rate.
935 SINGLE ACADEMIC INSTITUTION EXPERIENCE IN APPLICATION OF LAPAROENDOSCOPIC SINGLE-SITE SURGERY IN ADULT AND PEDIATRIC UROLOGIC SURGERY Seth Cohen*, George Chiang, Marvalyn DeCambre, Jonathan Silberstein, Sean Stroup, Jeffrey Woldrich, Wassim Bazzi, Ithaar Derweesh, San Diego, CA INTRODUCTION AND OBJECTIVES: Adoption of Laparoendoscopic Single-site surgery (LESS) into pediatric surgical practice represents a further development of the minimally invasive surgical armamentarium for pediatric urology. The extension of LESS has been undertaken in partnership between the adult and pediatric urologic surgeons at the University of California, San Diego. METHODS: Adult LESS (A-LESS) commenced in 1/2009, followed by initiation of Pediatric LESS (P-LESS) in 11/2009. Prior to initiation of P-LESS, pediatric urology faculty (GS, MD) proceeded with LESS-modified Society of American Gastrointestinal and Endoscopic Surgeons/Fundamentals of Laparoscopic Surgery curriculum emphasizing didactics, dry simulation drills, and preclinical live experience in partnership with the adult urologic surgeon (IHD). A-LESS were performed by transperitoneal (40) and retroperitoneal approach (20). Most (52) were performed by a single site approach with multiple trocars. All P-LESS were performed by transperitoneal SILS port (Covidien, Mansfield, MA, USA). Patient demographics, intraoperative parameters, outcomes, and complications were recorded. RESULTS: 60 A-LESS and 15 P-LESS have been performed. A-LESS included 29 radical and 17 partial nephrectomies, 6 nephrectomies with renal vein thrombectomies, and 7 adrenalectomies. P-LESS included 7 unilateral and 4 bilateral nephrectomies, 1 ureteral reimplant, 1 varicocelectomy, and 2 orchidopexies. One adult case each required conversion to open, multiport laparoscopy, or placement of second trocar at separate site. One P-LESS converted to open surgery. Median age (years, range) for A-LESS was 62.5 (24 – 85.6), and for P-LESS was 6 (1.2–17.9 years). Median hospital stay (hours) for A-LESS was 60, and for P-LESS was 51.6. Median operative times (minutes, range) for A- and P-LESS were 154 (35–220) and 183 (58 –564). Median estimated blood loss (mL, range) for A-LESS was 100 (5–500) and for P-LESS was 10 (0 –100). Median discharge pain score for A-LESS (visual analog scale, range) was 1 (0 – 4); median pain score (Faces, Legs, Activity, Cry Consolability scale, range) on post-operative day 1 for P-LESS was 2.2 (0 – 4.4). Complications were noted in 4 (6.7%) A-LESS and 0 P-LESS. CONCLUSIONS: Adaptation of LESS technique with excellent, reproducible and comparable outcomes was achieved by collaboration between adult and pediatric urologic surgeons. Further investigation is requisite to determine ultimate utility of LESS in adult and pediatric urology. Source of Funding: None
936 IS ROBOTIC ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY FINANCIALLY WORTHWHILE? Sammy Elsamra*, Andrew Leone, Michael Lasser, Simone Thavaseelan, George Haleblian, Gyan Pareek, Providence, RI INTRODUCTION AND OBJECTIVES: Robotic assisted laparoscopic partial nephrectomy (RALPN) is emerging as an alternative to laparoscopic partial nephrectomy for the surgical management of small renal masses. While, many studies may tout the benefits of RALPN, none have evaluated the financial cost of this approach. Herein, we evaluate the financial cost of RALPN as compared to hand-assisted laparoscopic partial nephrectomy (HALPN) at our institution. METHODS: All HALPN and RALPN from 2006 to 2010 were reviewed for patient age, size of tumor, operative times, and length of stay (LOS). Total cost of each procedure was based on operative room cost (time cost of room, anesthesia time cost, and supply) and hospital stay cost. Cost for common items (drapes, floseal, laparty, etc) and unique items (gel-port & harmonic for HALPN and robotic instrument arms for RALPN) was tabulated. These costs were applied to the mean HALPN and RALPN patient. Student’s t-test was utilized.
THE JOURNAL OF UROLOGY姞
e375
RESULTS: Of 100 minimally invasive partial nephrectomies (2006 –2010), 69 patients who fit study criteria were evaluated. 47 patients underwent HALPN and 21 patients underwent RALPN. The two groups were found to have similar age and tumor size. Room time and operative time were significantly shorter for the HALPN cohort (p⫽0.001) whereas LOS was significantly shorter in the RALPN cohort (p⫽0.019). In table 1 overall RALPN costs were $1,495 more than HALPN (HALPN-$7,917, RALPN-$9,409). While, the decreased LOS led to a cost savings of $228 for the RALPN cohort, the increased time in the OR led to an increased cost of $1225 (OR time fee and anesthesia fee). Further, the cost of surgical supplies was $495 greater for the RALPN. Medicare re-imbursement rates for the urologist were not included as the same billing codes are applied for both procedures. CONCLUSIONS: Our data reveals that while LOS is significantly shorter for RALPN, operative and room times were significantly greater. The cost advantage associated with decreased length of stay for RALPN did not recover the greater financial cost associated with increased surgery time, OR time, and robotic equipment. Given the current status of our healthcare system and the economy, one must consider the financial implications of new technology and whether this financial cost is met with real patient benefit.
Source of Funding: None
937 PERI-OPERATIVE OUTCOMES AND EARLY COMPLICATION RATES AFTER 4000 ROBOT ASSISTED RADICAL PROSTATECTOMIES Sanket Chauhan*, Rafael Coelho, Ananthakrishnan Sivaraman, Kenneth Palmer, Bernardo Rocco, Vipul Patel, Celebration, FL INTRODUCTION AND OBJECTIVES: Robot Assisted Radical Prostatectomy (RARP) is a rapidly evolving minimally invasive treatment modality for clinically localized prostate cancer. We report single surgeon experience with 4000 consecutive cases analyzing the perioperative outcomes and early complications. METHODS: After IRB approval, we retrospectively analyzed 4000 consecutive cases of RARP. All cases were performed via a 6 port trans-peritoneal technique. The complications were classified according to the Clavien grading system. RESULTS: Patient demographics are listed in Table 1. The median (IQR) OR time and blood loss were respectively 75 min (75– 80) and 100 ml (100 –150) while the median length of hospital stay and days on catheter were 1 day (1–1) and 5 days (4 – 6) respectively. The overall positive margin rate was 11.1% (pT2: 5.8%, pT3: 27.1%, pT4: 51.6%). Overall, 224 patients had 246 complications (6.1%). The most common peri-operative complication was ileus (0.7%) followed by bleeding requiring blood transfusions (0.5%). Intra-operatively, two patients (0.05%) had rectal injury while one patient (0.03%) had a small bowel injury during lysis of adhesions by general surgery. Two surgeries had to be converted laparoscopically due to system malfunction. The most common post operative complication was anastomosis leak (1.9%) followed by acute urinary retention (0.63%) [Table 2].
e376
THE JOURNAL OF UROLOGY姞
The incidence of minor complications (Clavien 1⫹2) was 5.1%, while that of major complications (Clavien grade 3⫹4) was 0.95%. Two patients (0.05%) died within 90 days of surgery, both unrelated to the robotic procedure: one had a cavernous sinus thrombosis, while the other had a post-operative myocardial infarction. CONCLUSIONS: After a decade of evolution, mature series reporting the outcomes of RARP are now available. These can be used to counsel the patients while explaining the peri-operative outcomes and complications of RARP.
Vol. 185, No. 4S, Supplement, Monday, May 16, 2011
938 NEEDLE STEERING SYSTEM USING DUTY-CYCLED ROTATION FOR PERCUTANEOUS KIDNEY ACCESS Khaled Shahrour*, Michael Ost, Nathan Wood, Stephen Jackman, Timothy Averch, Cameron Riviere, Pittsburgh, PA INTRODUCTION AND OBJECTIVES: A novel technique of percutaneous renal access (PRA) is needed to overcome the drawbacks of using rigid needles. If a flexible needle with a beveled tip is inserted into tissue, it will bend in the direction of the tip. The curve depends on the needle flexibility and tissue resistance. If the needle spins constantly during insertion, it follows a straight path as the bevel is negated. Alternating periods of spinning and stopping (duty-cycling) allows for proportional control of the trajectory in order to steer the needle in tissue non-traumatically. Our objective is to test the ability of the duty-cycled steerable needle system to follow a specific trajectory in vitro using phantom and swine kidneys. METHODS: The nitinol needle has a 0.52mm diameter with a 7° bevel and is attached to a motor for inserting motion and to another motor for spinning. The system is controlled using a graphical user interface to automatically select tip orientation, insertion and spinning speeds based on the actual needle position. A PRA phantom kidney training model was used in which the minor calyces were set as target points and needle is followed in real-time by a camera. In swine experiments, needle is followed fluoroscopically into the contrast-filled calyces. The distance between the actual path of the needle and the planned path (cross track error) and the final needle position were the objective and subjective outcomes respectively. RESULTS: The needle successfully entered the phantom and swine kidneys during all attempts. Mean cross track error was 0.71mm with a range between 0.05mm and 1.4mm in phantoms. In swine kidneys, the mean cross track error was 1.38 mm. CONCLUSIONS: Duty-cycled needle can be successfully steered along a pre-planed path in vitro and in swine kidney. Further studies on cadaveric and live animals are warranted prior to clinical investigation.
Source of Funding: None
939 USE OF ROBOTIC ASSISTED RADICAL CYSTECTOMY VERSUS OPEN RADICAL CYSTECTOMY FOR BLADDER CANCER IS ASSOCIATED WITH DECREASED BLOOD LOSS AND PERIOPERATIVE TRANSFUSION RATE Stephen Kappa*, Nashville, TN; Shady Salem, Shebin El-Koom, Egypt; Sam Chang, Peter Clark, Michael Cookson, Rodney Davis, David Penson, Roxy Baumgartner, Chad You, Joseph Smith, Daniel Barocas, Nashville, TN
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Blood loss and perioperative transfusions are important markers of clinical outcomes after radical cystectomy for bladder cancer. We compared Robotic Assisted Radical Cystectomy (RARC) versus Open Radical Cystectomy (ORC) to determine the effect of surgical approach on blood loss and perioperative transfusion rate.