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CAN STANDARDIZED FROZEN SECTIONS IN LAPAROSCOPIC EXTRA PERITONEAL PROSTATECTOMY REDUCE THE NUMBER OF POSITIVE MARGINS?
715 DOES OBESITY CONTRIBUTE TO ROBOTIC ARM COLLISIONS DURING ROBOTIC RADICAL PROSTATECTOMY?
716 TOTAL RECONSTRUCTION OF THE VESICO-URETHRAL JUNCTION: TECHNIQUE FOR EARLY RETURN OF URINARY CONTINENCE IN PATIENTS UNDERGOING ROBOTIC PROSTATECTOMY
Jhaveri K., Yadav R., Rao S., Leung R., Berryhill R., Tewari A. Weill Cornell Medical College, Dept. of Urology, New York, United States of America Introduction & Objectives: 5RERWLFUDGLFDOSURVWDWHFWRP\RᚎHUVDYDOXDEOHWUHDWPHQW FKRLFH WR PDQ\ GLᚎHUHQW W\SHV RI SDWLHQWV 2EHVH SDWLHQWV KDYH EHHQ GLᚑFXOW IRU laparoscopic surgeons to operate on historically, and one of the major reasons is because of improper port placement. We describe our “Rule of 20” for robotic port placement and our experience with obese patients. Material & Methods: Between January 2007 and July 2007, we prospectively HYDOXDWHG RXU SDWLHQWV ZKR ZHUH REHVH %0, JUHDWHU WKDQ DQG HYDOXDWHG LQ SDUWLFXODU WKH QXPEHU RI FROOLVLRQV EHWZHHQ URERWLF DUPV WKH GLᚑFXOW\ LQ UHDFKLQJ contralateral vessels. The pannus was retracted away from the midline and we employed our “Rule of 20” which is, using the root of the penis as a visible landmark for robotic port placement. We measured 20 cm from the root of the penis and placed the camera port just under the umbilicus. We then placed the rest of our robotic ports in standardized fashion around the camera port. The “Rule of 20” is an MRI based study which states that if the functional length of the robotic arm is the hypotenuse of a right triangle, the distance between the root of the penis and the membranous urethra is the base of a triangle then the height of the triangle averages out to be approximately 20cm, and we have been using this theory for port placement since the study.
Tewari A.1, Jhaveri J.1, Rao S.1, Yadav R.1, Bartsch G.2, Te A. ,RᚎH (1, Pineda M.1, Mudaliar S.1, Lang N.1, Libertino J.4, Vaughan E.1 1
Weill Cornell Medical College, Dept. of Urology, New York, United States of America, Innsbruck Medical University, Urology, Innsbruck, Austria, Weill Medical College, Medical University, New York, United States of America, 4Lahey Clinic Medical Centre, Dept. of Urology, Burlington, United States of America 2
Introduction & Objectives: To describe a novel technique of total vesico-urethral reconstruction, which combines the tactics of previous surgeons, and to compare the outcome of our innovative changes for return to early continence with prostatectomies with no or partial reconstruction of the vesico-urethral junction. Material & Methods: Between 1 January 2005 and 5 June 2007 a cohort of 700 patients undergoing robotic radical prostatectomy were prospectively evaluated. Patients in 2005 (214) served as a control group, they received no additional methods to provide support to the YHVLFRXUHWKUDOMXQFWLRQ DVWDQGDUGDQDVWRPRVLVZDVPDGH3DWLHQWVLQ UHFHLYHG an anterior reconstruction only, to provide additional vesico-urethral anastomotic support. Patients in 2007 (182) received the total reconstructive procedure, which included an anterior reconstruction and posterior reconstruction. Outcome data were collected using standardized health-related quality-of-life measures, which included the Expanded Prostate Cancer Index Composite survey, International Prostate Symptom Score, International Index of Erectile )XQFWLRQDQGWKHQUHYHULᚏHGE\WHOHSKRQHLQWHUYLHZZLWKDVWDQGDUGL]HGTXHVWLRQQDLUH7KH IROORZXSLQWHUYDOVZHUHDQGZHHNV&RQWLQHQFHZDVGHᚏQHGDVQRSDGXVDJH or one small liner used for security purposes only. Baseline variables were also collected.
Results: 15 patients were analyzed who were considered to be obese. Tumor characteristics and other pre operative factors were compared and found to not be VWDWLVWLFDOO\ VLJQLᚏFDQW $UP FROOLVLRQV GLᚑFXOW\ LVRODWLQJ FRQWUDODWHUDO YHVVHOV DQG GLᚑFXOW\SHUIRUPLQJO\PSKDGHQHFWRPLHVDVDUHVXOWRIGLVWDQFHZHUHUHFRUGHG:H noted only 2 patients to have robotic arm collisions, while isolating the contralateral vessels and lymphadenectomies were not problematic. No other operative morbidity was noted.
Results: The percentage of patients who had achieved continence in the control group were: DQGDWWKHDQGZHHNIROORZXSUHVSHFWLYHO\7KH percentage of patients who had achieved continence in the anterior reconstruction group were 27%, 59%, 77%, 86%, and 91%, respectively. The total reconstruction group had continence UDWHVRI DQG DWDQGZHHNVUHVSHFWLYHO\$WDOOWKHIROORZXS LQWHUYDOV WKH FRQWLQHQFH UDWH ZDV VLJQLᚏFDQWO\ OHVV LQ WKH FRQWURO JURXS WKDQ LQ WKH DQWHULRU reconstruction group and the total reconstruction group (P < 0.01)
Conclusions: From our preliminary analysis, we deem that using the “Rule of 20” for robotic port placement in obese patients does provide for adequate distance when operating. Even with obese patients, instrument collision was minimal and there was QRDGGLWLRQDOGLᚑFXOW\LQLVRODWLQJRWKHUVWUXFWXUHVGXULQJVXUJHU\
Conclusions: 7KHWRWDOUHFRQVWUXFWLRQSURFHGXUHLVDVDIHDQGHᚎHFWLYHZD\WRDFKLHYHDQ HDUO\UHWXUQWRFRQWLQHQFH1RDGYHUVHHᚎHFWVKDYHEHHQREVHUYHGEHFDXVHRILWVHPSOR\PHQW DQGRXUGDWDYDOLGDWHVWKDWLWGRHVSURYLGHDVWDWLVWLFDOO\VLJQLᚏFDQWHDUO\UHWXUQWRFRQWLQHQFH FRPSDUHGZLWKQRUHFRQVWUXFWLYHHᚎRUWVRUZLWKRQO\DQWHULRUUHFRQVWUXFWLYHHᚎRUWV
717
718
TENSION AND ENERGY-FREE ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY WITH LATERAL DISSECTION DISSECTION OF THE NEUROVASCULAR BUNDLES: 1 YEAR FOLLOW UP
CAN STANDARDIZED FROZEN SECTIONS IN LAPAROSCOPIC EXTRA PERITONEAL PROSTATECTOMY REDUCE THE NUMBER OF POSITIVE MARGINS?
Naspro R., Mattei A., Annino F., Piechaud T., Gaston R. Clinic Saint Augustin, Dept. of Urology, Bordeaux, France Introduction & Objectives: To assess oncological and functional outcomes at one year follow-up after robotic-assisted laparoscopic radical prostatectomy (RALP) with a new lateral approach for the dissection of the neurovascular bundles without tension and any use of electrocautery. Material & Methods: Between April and September 2006, 100 consecutive patients ZLWK RUJDQFRQᚏQHG SURVWDWH FDQFHU DJH \UV 36$ืQJGO *OHDVRQ VFRUHื DQG,,()ุ XQGHUZHQW5$/3E\WKHVDPHVHQLRUVXUJHRQ3UHLQWUDSHULDQGSRVW operative data were recorded. Patients were assessed at the 4 and 12 month followup. Results: RALP was successfully completed in all patients. Neither blood transfusions nor early re-intervention were necessary. One week following catheter removal, complete early urinary continence was achieved in 80% of patients, and spontaneous erections or penile tumescence were reported by 46 patients (46%) without the use of PDE-5 inhibitors. Positive surgical margins were 12.1% in the pT2 group and 29% in the S7JURXS2XWRIWKHVHWHQSDWLHQWVVXEVHTXHQWO\XQGHUZHQWDGMXYDQWUDGLRWKHUDS\ 1LQHW\WKUHH SDWLHQWV DQG IRUW\ SDWLHQWV ZHUH DYDLODEOH IRU WKH DQG month follow-up, respectively. Total median serum PSA levels were 0,020 ng/dl(0-0.50), 1 year from surgery. At the 4 month follow-up, 86(92.4%) were completely continent, the use of 1 pad per day was reported in 5 patients (5.4%), and only 2 patients (2.2%) used 2 or more pads per day. At 12 month follow-up, overall 95% of patients were completely continent and 5% referred the use of 1 pad a day. Median IIEF-EF domain VFRUH ZDV DQG WKH XVH RI 3'( LQKLELWRUV IRU LQWHUFRXUVH ZDV UHSRUWHG LQ 27.5% of patients after 1 year. No patient underwent re-intervention either for urethral or anastomotic stricture. Conclusions: The novel approach described for RALP is safe and allows excellent GLVVHFWLRQ )XUWKHUPRUH LW SURYLGHG DFFHSWDEOH PDUJLQ VWDWXV RᚎHULQJ HQFRXUDJLQJ oncological and functional results at 1 year follow-up in selected patients. Longer followup is necessary to assess the true impact of this approach on oncological outcomes.
Eur Urol Suppl 2008;7(3):250
Westphal J.1, Anheuser P.1, Batzill W.1, Krings T.1, Talimi S.1, Cordia I.1, Ansorge M.2, Graupner H.2 1 St. Josefshospital Uerdingen, Dept. of Urology, Krefeld, Germany, 2Institute of Pathology, Dept. of Pathology, Wesel, Germany
Introduction & Objectives: We carried out 460 laparoscopic extra SHULWRQHDO SURVWDWHFWRPLHV LQ RXU GHSDUWPHQW EHWZHHQ DXJXVW DQG 2FWREHU,QUHWURVSHFWWKHLQᚐXHQFHRIVWDQGDUGL]HGIUR]HQVHFWLRQV on the number of positive margins was examined. Material & Methods: The number of positive margins was examined on 460 specimen in total. After 101 cases we introduced standardized frozen sections of the specimen (margins apical, lateral and basic were inkmarked). Results: :LWKWKHᚏUVWFDVHVDFRPPRQKLVWRORJLFDOH[DPLQDWLRQZDV carried out. In 21,8% positive margins were detected overall. 12,5% for S7WXPRXUVIRUS7DDQGIRUS7EWXPRXUV$IWHUWKH introduction of standardized frozen sections we determined a rate of 7,2% LQDOOVWDJHVRIWXPRXUIRUS7WXPRXUVIRUS7DDQG IRUS7EWXPRXUV Conclusions: After introducing standardized frozen sections, the number of positive margins in all stages of tumour could be reduced. It needs to be discussed if this is only determined by the surgeons learning curve. It can be stated that the surgeon thus gains more oncological information and certainty in cooperating with his pathologist. We have to look at the data in future for PSA-relapse and progression free survival in comparison to the margin status earliest 5 years after radical prostatectomy.
716 TOTAL RECONSTRUCTION OF THE VESICO-URETHRAL JUNCTION: TECHNIQUE FOR EARLY RETURN OF URINARY CONTINENCE IN PATIENTS UNDERGOING ROBOTIC PROSTATECTOMY
Jhaveri K., Yadav R., Rao S., Leung R., Berryhill R., Tewari A. Weill Cornell Medical College, Dept. of Urology, New York, United States of America Introduction & Objectives: 5RERWLFUDGLFDOSURVWDWHFWRP\RᚎHUVDYDOXDEOHWUHDWPHQW FKRLFH WR PDQ\ GLᚎHUHQW W\SHV RI SDWLHQWV 2EHVH SDWLHQWV KDYH EHHQ GLᚑFXOW IRU laparoscopic surgeons to operate on historically, and one of the major reasons is because of improper port placement. We describe our “Rule of 20” for robotic port placement and our experience with obese patients. Material & Methods: Between January 2007 and July 2007, we prospectively HYDOXDWHG RXU SDWLHQWV ZKR ZHUH REHVH %0, JUHDWHU WKDQ DQG HYDOXDWHG LQ SDUWLFXODU WKH QXPEHU RI FROOLVLRQV EHWZHHQ URERWLF DUPV WKH GLᚑFXOW\ LQ UHDFKLQJ contralateral vessels. The pannus was retracted away from the midline and we employed our “Rule of 20” which is, using the root of the penis as a visible landmark for robotic port placement. We measured 20 cm from the root of the penis and placed the camera port just under the umbilicus. We then placed the rest of our robotic ports in standardized fashion around the camera port. The “Rule of 20” is an MRI based study which states that if the functional length of the robotic arm is the hypotenuse of a right triangle, the distance between the root of the penis and the membranous urethra is the base of a triangle then the height of the triangle averages out to be approximately 20cm, and we have been using this theory for port placement since the study.
Tewari A.1, Jhaveri J.1, Rao S.1, Yadav R.1, Bartsch G.2, Te A. ,RᚎH (1, Pineda M.1, Mudaliar S.1, Lang N.1, Libertino J.4, Vaughan E.1 1
Weill Cornell Medical College, Dept. of Urology, New York, United States of America, Innsbruck Medical University, Urology, Innsbruck, Austria, Weill Medical College, Medical University, New York, United States of America, 4Lahey Clinic Medical Centre, Dept. of Urology, Burlington, United States of America 2
Introduction & Objectives: To describe a novel technique of total vesico-urethral reconstruction, which combines the tactics of previous surgeons, and to compare the outcome of our innovative changes for return to early continence with prostatectomies with no or partial reconstruction of the vesico-urethral junction. Material & Methods: Between 1 January 2005 and 5 June 2007 a cohort of 700 patients undergoing robotic radical prostatectomy were prospectively evaluated. Patients in 2005 (214) served as a control group, they received no additional methods to provide support to the YHVLFRXUHWKUDOMXQFWLRQ DVWDQGDUGDQDVWRPRVLVZDVPDGH3DWLHQWVLQ UHFHLYHG an anterior reconstruction only, to provide additional vesico-urethral anastomotic support. Patients in 2007 (182) received the total reconstructive procedure, which included an anterior reconstruction and posterior reconstruction. Outcome data were collected using standardized health-related quality-of-life measures, which included the Expanded Prostate Cancer Index Composite survey, International Prostate Symptom Score, International Index of Erectile )XQFWLRQDQGWKHQUHYHULᚏHGE\WHOHSKRQHLQWHUYLHZZLWKDVWDQGDUGL]HGTXHVWLRQQDLUH7KH IROORZXSLQWHUYDOVZHUHDQGZHHNV&RQWLQHQFHZDVGHᚏQHGDVQRSDGXVDJH or one small liner used for security purposes only. Baseline variables were also collected.
Results: 15 patients were analyzed who were considered to be obese. Tumor characteristics and other pre operative factors were compared and found to not be VWDWLVWLFDOO\ VLJQLᚏFDQW $UP FROOLVLRQV GLᚑFXOW\ LVRODWLQJ FRQWUDODWHUDO YHVVHOV DQG GLᚑFXOW\SHUIRUPLQJO\PSKDGHQHFWRPLHVDVDUHVXOWRIGLVWDQFHZHUHUHFRUGHG:H noted only 2 patients to have robotic arm collisions, while isolating the contralateral vessels and lymphadenectomies were not problematic. No other operative morbidity was noted.
Results: The percentage of patients who had achieved continence in the control group were: DQGDWWKHDQGZHHNIROORZXSUHVSHFWLYHO\7KH percentage of patients who had achieved continence in the anterior reconstruction group were 27%, 59%, 77%, 86%, and 91%, respectively. The total reconstruction group had continence UDWHVRI DQG DWDQGZHHNVUHVSHFWLYHO\$WDOOWKHIROORZXS LQWHUYDOV WKH FRQWLQHQFH UDWH ZDV VLJQLᚏFDQWO\ OHVV LQ WKH FRQWURO JURXS WKDQ LQ WKH DQWHULRU reconstruction group and the total reconstruction group (P < 0.01)
Conclusions: From our preliminary analysis, we deem that using the “Rule of 20” for robotic port placement in obese patients does provide for adequate distance when operating. Even with obese patients, instrument collision was minimal and there was QRDGGLWLRQDOGLᚑFXOW\LQLVRODWLQJRWKHUVWUXFWXUHVGXULQJVXUJHU\
Conclusions: 7KHWRWDOUHFRQVWUXFWLRQSURFHGXUHLVDVDIHDQGHᚎHFWLYHZD\WRDFKLHYHDQ HDUO\UHWXUQWRFRQWLQHQFH1RDGYHUVHHᚎHFWVKDYHEHHQREVHUYHGEHFDXVHRILWVHPSOR\PHQW DQGRXUGDWDYDOLGDWHVWKDWLWGRHVSURYLGHDVWDWLVWLFDOO\VLJQLᚏFDQWHDUO\UHWXUQWRFRQWLQHQFH FRPSDUHGZLWKQRUHFRQVWUXFWLYHHᚎRUWVRUZLWKRQO\DQWHULRUUHFRQVWUXFWLYHHᚎRUWV
717
718
TENSION AND ENERGY-FREE ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY WITH LATERAL DISSECTION DISSECTION OF THE NEUROVASCULAR BUNDLES: 1 YEAR FOLLOW UP
CAN STANDARDIZED FROZEN SECTIONS IN LAPAROSCOPIC EXTRA PERITONEAL PROSTATECTOMY REDUCE THE NUMBER OF POSITIVE MARGINS?
Naspro R., Mattei A., Annino F., Piechaud T., Gaston R. Clinic Saint Augustin, Dept. of Urology, Bordeaux, France Introduction & Objectives: To assess oncological and functional outcomes at one year follow-up after robotic-assisted laparoscopic radical prostatectomy (RALP) with a new lateral approach for the dissection of the neurovascular bundles without tension and any use of electrocautery. Material & Methods: Between April and September 2006, 100 consecutive patients ZLWK RUJDQFRQᚏQHG SURVWDWH FDQFHU DJH \UV 36$ืQJGO *OHDVRQ VFRUHื DQG,,()ุ XQGHUZHQW5$/3E\WKHVDPHVHQLRUVXUJHRQ3UHLQWUDSHULDQGSRVW operative data were recorded. Patients were assessed at the 4 and 12 month followup. Results: RALP was successfully completed in all patients. Neither blood transfusions nor early re-intervention were necessary. One week following catheter removal, complete early urinary continence was achieved in 80% of patients, and spontaneous erections or penile tumescence were reported by 46 patients (46%) without the use of PDE-5 inhibitors. Positive surgical margins were 12.1% in the pT2 group and 29% in the S7JURXS2XWRIWKHVHWHQSDWLHQWVVXEVHTXHQWO\XQGHUZHQWDGMXYDQWUDGLRWKHUDS\ 1LQHW\WKUHH SDWLHQWV DQG IRUW\ SDWLHQWV ZHUH DYDLODEOH IRU WKH DQG month follow-up, respectively. Total median serum PSA levels were 0,020 ng/dl(0-0.50), 1 year from surgery. At the 4 month follow-up, 86(92.4%) were completely continent, the use of 1 pad per day was reported in 5 patients (5.4%), and only 2 patients (2.2%) used 2 or more pads per day. At 12 month follow-up, overall 95% of patients were completely continent and 5% referred the use of 1 pad a day. Median IIEF-EF domain VFRUH ZDV DQG WKH XVH RI 3'( LQKLELWRUV IRU LQWHUFRXUVH ZDV UHSRUWHG LQ 27.5% of patients after 1 year. No patient underwent re-intervention either for urethral or anastomotic stricture. Conclusions: The novel approach described for RALP is safe and allows excellent GLVVHFWLRQ )XUWKHUPRUH LW SURYLGHG DFFHSWDEOH PDUJLQ VWDWXV RᚎHULQJ HQFRXUDJLQJ oncological and functional results at 1 year follow-up in selected patients. Longer followup is necessary to assess the true impact of this approach on oncological outcomes.
Eur Urol Suppl 2008;7(3):250
Westphal J.1, Anheuser P.1, Batzill W.1, Krings T.1, Talimi S.1, Cordia I.1, Ansorge M.2, Graupner H.2 1 St. Josefshospital Uerdingen, Dept. of Urology, Krefeld, Germany, 2Institute of Pathology, Dept. of Pathology, Wesel, Germany
Introduction & Objectives: We carried out 460 laparoscopic extra SHULWRQHDO SURVWDWHFWRPLHV LQ RXU GHSDUWPHQW EHWZHHQ DXJXVW DQG 2FWREHU,QUHWURVSHFWWKHLQᚐXHQFHRIVWDQGDUGL]HGIUR]HQVHFWLRQV on the number of positive margins was examined. Material & Methods: The number of positive margins was examined on 460 specimen in total. After 101 cases we introduced standardized frozen sections of the specimen (margins apical, lateral and basic were inkmarked). Results: :LWKWKHᚏUVWFDVHVDFRPPRQKLVWRORJLFDOH[DPLQDWLRQZDV carried out. In 21,8% positive margins were detected overall. 12,5% for S7WXPRXUVIRUS7DDQGIRUS7EWXPRXUV$IWHUWKH introduction of standardized frozen sections we determined a rate of 7,2% LQDOOVWDJHVRIWXPRXUIRUS7WXPRXUVIRUS7DDQG IRUS7EWXPRXUV Conclusions: After introducing standardized frozen sections, the number of positive margins in all stages of tumour could be reduced. It needs to be discussed if this is only determined by the surgeons learning curve. It can be stated that the surgeon thus gains more oncological information and certainty in cooperating with his pathologist. We have to look at the data in future for PSA-relapse and progression free survival in comparison to the margin status earliest 5 years after radical prostatectomy.