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Abstract: Objective: To evaluate the initial functional and oncologic results of 184 robot-assisted radical prostatectomies performed at our hospital. Methods: A retrospective study was made of the first 184 consecutive robot-assisted radical prostatectomies performed at our hospital between February 2003 and December 2005. The procedures were performed by two surgeons who used the da Vinci robot with three robot arms. A transperitoneal approach was used in all patients. All patients had clinically organ-confined prostate cancer (≤cT2c). The median follow-up was 6 mo. Results: A positive surgical margin was found in 29 of the 184 patients (mean: 15.7%). The percentage positive surgical margins for the organ-confined (pT2) and non–organ-confined prostate cancers (pT3) were 2.5% and 38%, respectively. Ninety-five percent of patients were completely continent or wore one safety liner. Forty-three percent of the continent patients achieved complete continence within 28 d. Eighty-one percent of the patients who were younger than 60 yr and received a nerve-sparing procedure were potent and able to perform sexual intercourse. This percentage dropped to 51% in patients older than 60 yr. No major complications were encountered. Conclusions: The functional and oncologic results of this minimally invasive procedure seem very promising. Longer follow-up of the data and larger prospective studies are necessary to confirm these promising results. [Copyright &y& Elsevier]

Abstract: Objective: Laparoscopic partial nephrectomy is gaining acceptance as an alternative to open surgery for small renal tumours, although technical difficulty of intracorporeal suturing and concerns over warm ischemia time are limitations. Previous work has demonstrated that suturing with the robotic system is easier compared with laparoscopy. We believe the robot has an application and we report our initial experience in 10 patients undergoing robotic partial nephrectomy. Methods: Ten patients with small exophytic renal masses underwent intraperitoneal robotic partial nephrectomy. Principles of traditional open surgery were followed and intraoperative ultrasound was used to define resection margins. The renal artery was clamped with laparoscopic bulldog clamps and indigo carmine was administered intravenously to detect entry into collecting system. Suture closure and FLOSEAL were used for hemostasis. Frozen sections were obtained in all patients. Results: Seven men and three women, mean age 59 yr, underwent robotic partial nephrectomy. Mean tumour size was 2cm. Mean console and warm ischemia time were 158min and 21min, respectively. The median hospital stay was 1.5 d. Pathology revealed renal cell carcinoma in eight, oncocytoma in one, and lipoma in one. All resection margins were negative. Follow-up ranged from 6 to 28 mo. Conclusions: Robotic partial nephrectomy is a viable alternative to open or laparoscopic partial nephrectomy in carefully selected patients with small renal tumours. The advantages of the robotic system must be weighed against its cost. Further studies will determine if reduction in procedure complexity warrants the expense of such technology. [Copyright &y& Elsevier]

Abstract: Objective: We have recently described a modification (Veil of Aphrodite) designed to preserve the lateral prostatic fascia (LPF) during robotic prostatectomy. Here, we histologically compare the Veil of Aphrodite technique (VT) and standard nerve-sparing technique (ST). Methods: Thirty-six consecutive prostatectomies performed by a single surgeon were processed by the whole-mount method. The right and left anterolateral (AL) zones of each prostate were independently evaluated for LPF, plane of excision, capsular incision/margin status, margin clearance, and quantitative analysis of periprostatic nerve bundles using S100 immunostain. Results: There were 42 AL zones with ST and 30 with VT. In all 42 ST zones, the plane of excision was outside the prostate and a rim of LPF was present. The mean margin clearance was 1.4mm (0.6–2.8mm) and the mean nerve bundle count was 10 (3–19). Capsular incision and margin status were negative in all 42. For VT, 24 of 30 zones lacked LPF and the plane of excision ran just by the prostatic edge. The mean margin clearance was 0.3mm (0–1.7mm) and the mean nerve bundle count was two (0–11). Two VT AL zones revealed capsular incision; the margin was negative for tumour in all 30. Differences in the margin clearances and nerve bundle counts between ST and VT were statistically significant (p <0.0001). Conclusions: The LPF contains nerve bundles that run along the surface of the AL zones. The VT is a safe procedure that effectively preserves the LPF and appears to provide enhanced nerve sparing as compared to the ST. [Copyright &y& Elsevier]

Objective: To provide a detailed description of the steps involved in a laparoscopic radical prostatectomy in relation to the complex neurovascular anatomy of the male pelvis.Aim and hypothesis: We aimed at delineating the neurovascular anatomy to assist in nerve preservation during laparoscopic and robotic radical prostatectomies.Methods: A team of urologists and an anatomist performed anatomic dissections of 12 male cadavers using a combination of laparoscopic equipment, magnification, and open surgical dissection. Each step involved in laparoscopic prostatectomy was reviewed in relation to the possible impact the step could have on the neurovascular bundles.Results: Dissections were performed systematically to mimic various steps of laparoscopic and robotic prostatectomy. The neurovascular bundles were identified and correlated with video images of actual surgery. This enabled us to construct computer simulations and show the actual nerves on the operative pictures. We specially unraveled the relationship between neurovascular bundles and lateral pelvic and Denonvillier’s fascias, both of which enclose and hide these important structures. The course of the bundles was traced from its origin at pelvic plexus to its distal course along the urethra.We also showed the important relationship between pelvic plexus ganglions and seminal vesicles to illustrate the vulnerability of these nerves to thermal, electrical and/or crush injury during seminal vesicle and prostatic pedicle dissections. The importance of additional fine neural plexus along the posterior and antero-lateral surface of the prostate was shown by both gross anatomical and microscopic images. The distal precarious location of the bundles was illustrated by dissections showing anteriorly lifted prostate.These anatomico-operative correlations have not been published for laparoscopic and robotic prostatectomies, which differ significantly in its visual angles, magnifications and sometimes three-dimensional (3D) visualization from its open counter part.Conclusion: Laparoscopic and robotic radical prostatectomy provides exposure and visualization of male pelvis not previously appreciated. It is only through a careful reexamination of the anatomy of the male pelvis, in the context of this new procedure, that the improvements in visualization and exposure benefit the surgeon. Our work provides a detailed map relating to operative steps to aid the surgeon in the performance of a nerve sparing robotic and laparoscopic radical prostatectomy. [Copyright &y& Elsevier]

Urology has continuously embraced novel technologies like laparoscopy that reduce patient morbidity yet maintain an excellent standard of care. Because of limitations on maneuverability, operative vision, manual dexterity, and tactile sense, laparoscopy can be more difficult to perform than corresponding tasks in open surgery. To potentially increase clinical applicability of laparoscopy, robots that enhance operative performance have recently been introduced for a variety of laparoscopic procedures such as laparoscopic radical prostatectomy, pyeloplasty, and even laparoscopic cystectomy and neobladder construction. While these robots have generated excitement and many robotic applications have been described, the benefit of the advanced technology in expanded series of patients remains largely unknown. In addition, the ability of telerobotics to be used by surgeons inexperienced in conventional laparoscopy is also poorly understood. This review compares current features of available robots, advantages and limitations of robots, the emerging clinical applications, and the future potential of robotics in urology. [Copyright &y& Elsevier]

Purpose: Laparoscopic pyeloplasty is an accepted therapy for primary ureteropelvic junction obstruction (UPJO), however difficulty associated with intracorporeal suturing has limited widespread clinical application. We report our initial experience of laparoscopic pyeloplasty performed with the daVinci robotic system matched to procedures performed with standard laparoscopic techniques.Patients and Methods: From June 2001 until August 2001, six patients underwent definitive management of primary UPJO using the daVinci robotic system. In four patients an Anderson–Hynes pyeloplasty was performed, while in two patients Fengerplasty was performed. Using demographic and preoperative information, each patient in the daVinci-assisted group was matched to a corresponding patient with primary UPJO undergoing laparoscopic pyeloplasty with standard techniques between November 1999 and June 2001. Perioperative results and follow-up data were subsequently compared.Results: Treatment groups were identical with regard to surgical procedure, gender, and side of UPJO. The length of hospitalization was 4 days for all patients, regardless of treatment group. Estimated blood loss was <50 cc in all cases. For Anderson–Hynes pyeloplasty, the mean overall operative and suturing times were 140 and 70 min using the daVinci system and 235 and 120 min using standard techniques, respectively. For the Fengerplasty, the mean overall operative and suturing times were 78 and 13 minutes using the daVinci system and 100 and 28 minutes using standard techniques, respectively. No complications were observed and there were no open conversions.Conclusion: Anderson–Hynes pyeloplasty and Fengerplasty are feasible using either conventional laparoscopic techniques or the daVinci robotic system. In this initial pilot study, procedures performed with the daVinci robotic system resulted in overall decreased operative time, however factors responsible for the decreased operative time remain to be defined. Long-term prospective follow-up of procedures performed with or without the daVinci robotic system for surgeons with limited experience in laparoscopic management of UPJO is warranted to delineate the true efficacy of the device. [ABSTRACT FROM AUTHOR]

Purpose: To describe our technique of robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic neobladder (Hautmann) for treatment of transitional cell carcinoma of the bladder.Methods: We describe our surgical technique in the worldwide first attempt to perform a robotic-assisted laparoscopic radical cystectomy and completely intra-abdominal formation of an orthotopic neobladder. The DaVinci System™ (Intuitive Surgical, Mountain View, CA, USA) was utilized to perform the procedure.Results: Utilizing the DaVinci System the operation could be performed without any complications. Operating time was 8.5 hours, blood loss was 200 ml. The oncologic as well as the functional result of the reservoir were excellent.Discussion: We here demonstrated that sophisticated laparoscopic procedures like the intra-abdominal formation of an orthotopic neobladder are accomplishable with robotic assistance. [Copyright &y& Elsevier]