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Purpose: To determine whether the presence of median lobe (ML) affects perioperative outcomes, positive surgical margin (PSM) rates, and recovery of urinary continence after robot-assisted radical prostatectomy (RARP)., Patients and Methods: We analyzed 1693 consecutive patients undergoing RARP performed by a single surgeon. Patients were analyzed in two groups based on the presence or not of a ML identified during RARP. Perioperative outcomes, PSM rates, and recovery of urinary continence were compared between the groups. Continence was assessed using validated questionnaires, and it was defined as the use of "no pads" postoperatively., Results: A ML was identified in 323 (19%) patients. Both groups had similar estimated blood loss, length of hospital stay, pathologic stage, complication rates, anastomotic leakage rates, overall PSM rates, and PSM rate at the bladder neck. The median overall operative time was slightly greater in patients with ML (80 vs 75 min, P<0.001); however, there was no difference in the operative time when stratifying this result by prostate weight. Continence rates were also similar between patients with and without ML at 1 week (27.8% vs 27%, P=0.870), 4 weeks (42.3% vs 48%, P=0.136), 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 (median: 5 wks, 95% confidence interval [CI]: 4.41-5.59 vs median: 5 wks, CI 4.66-5.34; log rank test, P=0.113)., Conclusion: The presence of a ML does not affect outcomes of RARP performed by an experienced surgeon.

Natural orifice translumenal endoscopic surgery (NOTES) is a developing field with the potential to revolutionize our approach to abdominal surgery. Performing operations via a flexible endoscope introduced through a natural orifice presents several challenges to physicians. Orientation and interpretation of the endoscopic video image can be difficult. The surgeon must also learn to operate with the camera and instruments "in line." Advances in technology are currently addressing the challenges of NOTES. Image-guided navigation could potentially provide invaluable assistance during NOTES. Real-time information on spatial positioning and orientation as well as assistance with the identification of anatomy and localization of pathology are some of the possibilities. Image-guided surgery has become commonplace in disciplines such as neurosurgery where the anatomy is relatively rigid. To become widespread in intra-abdominal procedures and NOTES, advances that will allow systems to adapt to moving and deforming anatomy are needed. This article reviews the basics of image-guided surgery, the various image-guided systems, and their potential application to NOTES.

Background: Robot-assisted laparoscopic radical prostatectomy (RALP) is an evolving minimally invasive treatment of for localized prostate cancer. We present our experience of 1500 consecutive cases with an analysis of perioperative outcomes., Patients and Methods: Fifteen hundred consecutive RALPs were performed by a single surgeon (VRP). Following Institutional Review Board approval, clinical coordinators performed prospective intraoperative and postoperative data collection. Functional outcomes were assessed using validated self-administered questionnaires., Results: Mean OR time from skin incision to fascial closure (the time that the surgeon was present) was 105 minutes (55-300). Mean EBL was 111 cc (50-500). Ninety-seven percent of patients were discharged home on postoperative day 1. The overall complication rate was 4.3% with no mortalities. The positive margin rate (PMR) was 9.3% overall. PMR was 4% for pT2, 34% for T3 and 40% for pathologic stage T4., Conclusions: Our initial series represents one of the largest published series for perioperative outcomes of robotic assisted prostatectomy. Our data demonstrates the feasibility, safety and efficacy of the procedure.

Purpose: Robotic-assisted laparoscopic prostatectomy (RALP) is growing in popularity as a treatment option for prostate cancer. As a new technology, little is known regarding the reliability of the da Vinci robotic system. Intraoperative robotic equipment malfunction may force the surgeon to convert the procedure to an open or pure laparoscopic procedure, or possibly even abort the procedure. We report the first large-scale, multi-institutional review of robotic equipment malfunction., Materials and Methods: A questionnaire was designed to evaluate the rate of perioperative robotic malfunction during RALP. High-volume, experienced surgeons were asked to complete this evaluation based on the analysis of their data. Questions included the overall number of RALPs performed, the number of equipment malfunctions, the number of procedures that had to be converted or aborted, and the part of the robotic system that malfunctioned., Results: Eleven institutions participated in the study with a median surgeon volume of 700 cases, accounting for a total case volume of 8240. Critical failure occurred in 34 cases (0.4%) leading to the cancellation of 24 cases prior to the procedure, and the conversion to two laparoscopic and eight open procedures. The most common components of the robot to malfunction were the arms and optical system., Conclusions: Critical robotic equipment malfunction is extremely rare in institutions that perform high volumes of RALPs, with a nonrecoverable malfunction rate of only 0.4%.