Robotics in laparoscopic urology

Following the successful application of the da Vinci robot in minimally invasive radical prostatectomy, several surgeries are now being performed with the assistance of the robot. These include both upper tract and lower tract surgeries such as nephrectomy, pyeloplasty and sacrocolpopexy and both ablative and reconstructive procedures. This article attempts to put into perspective the current role of the da Vinci Surgical system in urologic surgery and discusses in brief new developments in robotic technology that are on the horizon. A MEDLINE search was performed and published data on robot-assisted urologic procedures were reviewed. Abstracts presented at major international conferences in the last two years were also reviewed. Studies presenting operative and functional data for more than five patients were used in the review. There has been an explosive increase in the number of urologic procedures being attempted using Da Vinci assistance. Many, such as partial nephrectomy, donor nephrectomy, cystoprostatectomy, ureteral reimplantation and vasovasostomy are in the phase of feasibility studies, however others such as radical prostatectomy and pyeloplasty have one year functional results available which are comparable to those of other minimally invasive approaches. We believe that robotic technology represents the future of minimally invasive surgery and applications for the robot will expand as more centers report their results.

Da Vinci assisted cystoprostatectomy and urinary diversion: a paradigm shift in surgical management of bladder cancer

Radical cystoprostatectomy remains the gold standard treatment for muscle invasive bladder cancer. Use of minimally invasive approaches have gained prominence aided by surgical adjuncts such as harmonic scalpel and laparoscopic bowel staplers, however laparoscopic radical cystoprostatectomy remains extremely technically challenging even for experienced laparoscopic surgeons. Following the successful application of the da Vinci robotic surgical system for radical prostatectomy, attention has now turned to the use of robot assistance for laparoscopic cystoprostatectomy. Several centers have explored the feasibility of robotic cystoprostatectomy although long-term data is lacking. Controversy exists on the oncologic efficacy and safety, need for intracorporeal diversion and standardization of technique. This article details the history, technique, results and current status of robotic cystoprostatectomy and urinary diversion.

A potential generic downstream process using Cibracon Blue resin at very high loading capacity produces a highly purified monoclonal antibody preparation from cell culture harvest

The use of a dye-ligand chromatography for the purification of monoclonal antibody (MAb) from cell culture and other feed streams has been largely overlooked in large scale production. Cibracon Blue dye (CB), a polycyclic anionic ligand, interacts with protein through a specific interaction between the dye, acting as a mimic of NAD+ and NADP+, or through non-specific electrostatic, hydrophobic, and other forces. In this paper, a CB resin was used to effectively and efficiently separate an IgG4 MAb from host and process impurities following the capture of the MAb on a Protein-A (PA) column. The CB unit operation, challenged at </=180 g MAb/L of resin with the PA eluate, reduced BSA (1-2 log), host cell protein (HCP; 2-3 log), MAb oligomer (31-85%), fragment (from approximately 0.8% to <0.1%), and other undesired MAb species. Purity, as measured by non-reducing (NR) SDS-PAGE, was improved 33-85%, to 92-99.5% overall (>99% by reducing SDS-PAGE). A facile three column scalable production scheme, employing CB as the second column in the process was used to generate highly purified MAb from cell culture harvest derived from two media of very different compositions. Free CB dye was </=1 ng/mg in MAb preparations purified through the three column process and then concentrated and buffer exchanged into the appropriate buffer using tangential flow filtration (TFF).

Development of robotic program: an Asian experience

Robotic surgery was started in the Department of Urology, Hospital Kuala Lumpur, in April 2004. We present our experience in developing the program and report the results of our first 50 cases of robotic radical prostatectomy. A three-arm da Vinci robotic system was installed in our hospital in March 2004. Prior to installation, the surgeons underwent training at various centers in the United States and Paris. The operating theatre was renovated to house the system. Subsequently, the initial few cases were done with the help of proctors. Data were prospectively collected on all patients who underwent robot-assisted radical prostatectomy for localized carcinoma of the prostate. Fifty patients underwent robot assisted radical prostatectomy from March 2004 to June 2005. Their ages ranged from 52 to 75 years, (average age 60.2 years). PSA levels ranged from 2.5 to 35 ng/ml (mean 10.6 ng/ml). Prostate volume ranged from 18 to 130 cc (average 32.4 cc). Average operating time for the first 20 cases was 4 h and for the next 30 cases was 2.5 h. Patients were discharged 1-3 days post-operatively. Catheters were removed on the fifth day following a cystogram. The positive margin rate as defined by the presence of cancer cells at the inked margin was 30%. Twenty-one patients had T1c disease and one had T1b on clinical staging. Of these, two were apical margin positive. Twenty-six patients had T2 disease and eight of them were apical margin positive. Two patients had T3 disease, one of whom was apical margin positive. Five patients (10%) had PSA recurrence. Five patients had a poorly differentiated carcinoma and the rest had Gleason 6 or 7. Eighty percent of the patients were continent on follow-up at 3 months. Of those who were potent before the surgery, 50% were potent at 3-6 months. The robotic surgery program was successfully implemented at our center on the lines of a structured program, developed at Vattikuti Urology Institute (VUI). We succeeded in creating a team and safely implemented the robotic program in our system. Adequate funding and extensive training followed by a short term proctoring are essential for this implementation.

pT1 SUBSTAGING IN RENAL CELL CARCINOMA: VALIDATION OF THE 2002 TNM STAGING MODIFICATION OF MALIGNANT RENAL EPITHELIAL TUMORS

PURPOSE

Tumor size has been used as one of the criteria to stratify renal cell carcinoma (RCC) into different pathological stages (pT). The recent 2002 UICC/TNM classification of malignant epithelial renal tumors is modified to substratify pT1 RCC into pT1a (less than 4.0 cm) and pT1b (greater than 4.0 but less than 7.0 cm). In this study we ascertained if this stage modification has prognostic relevance.

MATERIALS AND METHODS

A total of 259 consecutive radical nephrectomy specimens of organ confined RCC from 1970 to 1997 at 1 institution, including 153 of conventional RCC (CRCC), 71 of papillary RCC, 28 of chromophobe RCC, 1 of collecting duct carcinoma and 6 of RCC not otherwise specified, with a mean clinical followup of 7.5 years (median 6.4) were included in the study.

RESULTS

There were 115 pT1a (44.4%), 95 pT1b (36.7%) and 49 pT2 tumors (18.9%). Disease recurrences (DR) and disease specific death occurred in 2 (1.7%) and 0 cases (0%) of pT1a, 7 (7.3%) and 5 (5.3%) of pT1b, and 16 (32.6%) and 12 (24.5%) of pT2. DR for pT1b was higher compared with pT1a (all histological subtypes RR 3.68), although this difference was not statistically significant (p = 0.106). If only CRCCs were analyzed, DR in the pT1b group was statistically higher compared with pT1a (RR 8.54, p = 0.047). Disease specific survival in pT1a could not be evaluated because no deaths occurred in this subgroup. DR and disease specific survival were significantly different between pT1b and pT2 tumors for all histological subtypes (RR 5.51, p = 0.001 and 5.49, p = 0.001) and for the CRCC subtype (RR 5.50, p = 0.001 and 5.18, p = 0.005, respectively). Using size as a continuous variable the logarithmic change in tumor size was a significant predictor of DR (RR 8.82, p = 0.001). All statistical analyses were adjusted for age and sex.

CONCLUSIONS

Substaging RCC into pT1a and pT1b yields prognostically important information, validating the 2002 TNM modification for malignant renal epithelial malignancies. The substratification of pT1 is particularly useful in tumors with CRCC histology.

Autosomal dominant polycystic kidney disease and pain - a review of the disease from aetiology, evaluation, past surgical treatment options to current practice

Autosomal Dominant Polycystic Kidney Disease (ADPKD), often referred to as "adult" polycystic kidney disease, is one of the commonest hereditary disorders. It affects approximately 4 to 6 million individuals worldwide. The disease progresses to end-stage renal disease and it accounts for 10-15% of patients requiring dialysis in the United States. A comprehensive Medline search for aetiology, evaluation, screening, cellular biology, and treatment was utilized to locate, extract, and synthesize relevant data with respect to this topic. Special attention was focused on urologic literature and surgical textbooks regarding operative treatment of pain associated with ADPKD. Now, patients with ADPKD have more treatment options. More specifically, several therapeutic alternatives are now available for the management of pain in these patients. A recent review of literature supports the performance of open or laparoscopic cyst decortication procedures for control of pain and infection without the worry of causing further renal impairment in those with preserved renal function.

The technique of apical dissection of the prostate and urethrovesical anastomosis in robotic radical prostatectomy

OBJECTIVE

To describe the technique of dissecting the apex of the prostate and a modified single running-suture urethrovesical anastomosis in patients undergoing robot-assisted radical prostatectomy for organ-confined prostate cancer.

PATIENTS AND METHODS

Over 550 robot-assisted radical prostatectomies have been undertaken using Vattikuti Institute Prostatectomy (VIP) technique in patients with localized carcinoma of the prostate. We present a critical analysis of the first 120 procedures by one surgeon (M.M.) at our institution using this newly developed technique of urethrovesical anastomosis preceded by dissecting the apex of the prostate.

RESULTS

The mean time for the urethrovesical anastomosis was 13 min. All but 24 patients had their catheter removed 4 days after surgery, as indicated by a cystogram. The catheter was removed successfully at 7 days in the remaining 24 patients who had a mild leak on cystography. Two patients had urinary retention within a week of removing the catheter and had to be re-catheterized. Continence was evaluated using standardized criteria before and after the procedure. The patients also replied to a mailed validated questionnaire survey; 96% were continent at 3 months and the remaining 4% used a thin pad for security.

CONCLUSIONS

We report a technique of dissecting the apex of the prostate and prostatovesical junction for dividing the bladder neck, and a modified single running-suture urethrovesical anastomosis, in patients undergoing robot-assisted radical prostatectomy for organ-confined cancer of the prostate. The same principles can also be applied for the anastomosis during pure laparoscopic procedures and for urethro-neovesical anastomosis in patients undergoing robotic radical cystoprostatectomy for carcinoma of the bladder.

Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion

OBJECTIVE

To develop a technique of nerve-sparing robot-assisted radical cystoprostatectomy (RRCP) for patients with bladder cancer.

PATIENTS AND METHODS

Robotic assistance should enhance the ability to preserve the neurovascular bundles during laparoscopic radical cystectomy. Thus we undertook RRCP and urinary diversion using a three-step technique. First, using a six-port approach and the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), one surgeon carried out a complete pelvic lymphadenectomy and cystoprostatectomy using a technique developed specifically for robotic surgery. The neurovascular bundles were easily identified and dissected away, the specimen entrapped in a bag and removed through a 5-6 cm suprapubic incision. Second, a different surgical team exteriorized the bowel through this incision and created a neobladder extracorporeally. Third, the neobladder was internalized, the incision closed and the primary surgeon completed the urethro-neovesical anastomosis with robotic assistance.

RESULTS

RRCP was carried out in 14 men and three women by the primary surgeon (M.M.). The form of urinary reconstruction was ileal conduit in three, a W-pouch with a serosal-lined tunnel in 10, a double-chimney or a T-pouch with a serosal-lined tunnel in two each. The mean operative duration for robotic radical cystectomy, ileal conduit and orthotopic neobladder were 140, 120 and 168 min, respectively. The mean blood loss was < 150 mL. The number of lymph nodes removed was 4-27, with one patient having N1 disease. The margins of resection were free of tumour in all patients.

CONCLUSIONS

We developed a technique for nerve-sparing RRCP using the da Vinci system which allows precise and rapid removal of the bladder with minimal blood loss. The bowel segment can be exteriorized and the most complex form of orthotopic bladder can be created through the incision used to deliver the cystectomy specimen. Performing this part of the operation extracorporeally reduced the operative duration.

A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution

The authors from the Vattikuti Institute in the USA report a prospective comparison of radical prostatectomy and robot-assisted prostatectomy. They found that the robot-assisted procedure was safer, and yielded favourable oncological and functional results. They also present work in association with the Department of Urology in Mansoura into robot-assisted radical cystoprostatectomy and urinary diversion, and point out the advantages and disadvantages associated with performing the most complex types of urinary diversion. There is also an interesting paper relating to the association between sexual factors and prostate cancer, from authors in institutions in Australia, New Zealand and Italy. They found that in a case-control study of men aged <70 years, ejaculatory frequency was negatively associated with the risk of prostate cancer. Technology has made many contributions to the management of urological patients. The classic example is that of urinary stone management. Authors from the USA evaluated cyroablation of renal carcinoma in patients with solitary kidneys. They are encouraged by their results and suggest that there is merit in this treatment, but indicate the need for a longer follow-up.

OBJECTIVE

To prospectively compare standard radical retropubic prostatectomy (RRP) and the robotically assisted Vattikuti Institute prostatectomy (VIP) in the management of localized prostate cancer.

PATIENTS AND METHODS

The study was a single-institution, prospective, unrandomized comparison of histopathological, and functional outcomes, at baseline and during and after surgery, in 100 patients undergoing RRP and 200 undergoing VIP.

RESULTS

While the variables before surgery, the operative duration (163 vs 160 min) and pathological stages were comparable, there were significant differences in the measured outcomes. The blood loss was 910 and 150 mL for RRP and VIP, respectively, and transfusion was greater after RRP (67% vs none; both P < 0.001). There were four times as many complications after RRP (20% vs 5%, P < 0.05), the haemoglobin level at discharge was lower (100 vs 130 g/L, P < 0.005) and the hospital stay longer (3.5 vs 1.2 days; P < 0.05). Most (93%) of VIP and none of the RRP patients were discharged within 24 h (P < 0.001); the duration of catheterization was twice as long after RRP (15.8 vs 7 days; P < 0.05). Positive margin was more frequent after RRP (23% vs 9%, P < 0.05). After VIP, patients achieved continence and return of erections more quickly than after RRP (160 vs 44, and 180 vs 440 days, both P < 0.5). The median return to intercourse was 340 days after VIP but after RRP half the patients have as yet not resumed intercourse at 700 days (P < 0.05).

CONCLUSIONS

The VIP procedure appears to be safer, less bloody and requires shorter hospitalization and catheterization. The oncological and functional results were favourable in patients undergoing VIP.

The effect of fixation technique on graft position in anterior cruciate ligament reconstruction

The purpose of this paper was to determine the extent to which the technique used in ACL reconstruction and fixation influences graft placement. This is a Comparative Radiographic cohort study. Precise graft placement is one of the most crucial components of a successful anterior cruciate ligament (ACL) reconstruction. Two commonly used techniques of ACL reconstruction are arthroscopic bone-patellar tendon-bone (B-PT-B) autograft with interference screw fixation and semi-tendinosus and gracilis (ST + G) tendon autograft with endobutton femoral and multiple staple belt buckle tibial fixation. Using radiographic measurements of bone tunnel position following ACL reconstruction this study quantified the extent to which these techniques influenced graft placement. Femoral and tibial tunnel position in ACL reconstruction was determined using the post-operative radiographs of 40 male patients who had undergone ACL reconstruction (20 B-PT-B and 20 ST + G). The primary outcome measure was location of bone tunnel position following ACL reconstruction. Measurements were based on the guidelines of Amis et al. Femoral tunnel position of B-PT-B grafts was an average of 9.36% more anterior in the sagittal plane than with ST + G grafts. The mean position of B-PT-B grafts was at 31.11% (SD = 5.45%). The mean position of the ST + G grafts was 21.76% (SD = 6.62%). This difference between the two was found to be significant (p < .001). As demonstrated by this study, placement and orientation may vary to accommodate technique and fixation. Clinical outcomes measured were similar in both groups.

Modulation of bile acids induced by paraquat in rabbits

Rabbit bile was examined for changes in composition induced by paraquat. Paraquat was administered intraperitoneally and changes in bile components were monitored by high performance liquid chromatography. Alterations in the ratios of total glycine/taurine conjugated bile acids (TGC/TTC), cholic acid/deoxycholic acid (CA/DC), cholic acid/chenodeoxycholic acid (CA/CDC) and cholic acid/cholesterol (CA/CH) were measured as an index of paraquat toxicity. A statistically significant increase in the ratio of TGC/TTC was observed, while CA/DC, CA/CDC and CA/CH showed a decrease. Phospholipids, protein, sugar, bilirubin, beta-carotene, vitamin A and vitamin E in the bile and serum of the experimental animals were also monitored. In bile, the levels of cholesterol, phospholipids, protein, sugar, and total bile acids increased while the levels of the antioxidants beta-carotene, vitamin A and vitamin E decreased. A decrease in the bilirubin content of the bile was also observed. These modifications may be useful clinically for assessment of paraquat toxicity.

Effect of environmental pollutants on hepatocellular function in rats: 3-methylcholanthrene and Aroclor-1254

Environmental pollutants, Aroclor-1254 (PCB) and 3-methylcholanthrene (MC), were employed in this study to investigate some aspects of the induction of hepatic drug metabolism in rats. PCB and MC treatments increased 7-ethoxyresorufin and 7-ethoxycoumarin O-deethylase activities related to cytochrome P-448. Cytochrome P-450 reductase activity was increased by PCB while no effect was observed by MC treatment. Pretreatment with PCB resulted in approximately 50% increase in the phospholipid content of the microsomes whereas MC caused no change. Liver microsomal cholesterol content was decreased while triglycerides were increased by PCB. The ratio between saturated and unsaturated fatty acids (saturation index) decreased in the total microsomes and phospholipids with PCB treatment, whereas MC did not alter the ratio, except that the major effect of MC was observed in the acyl derivatives of microsomal phosphatidylethanolamine. It is proposed that the uniaxial rotation and mobility of hemoproteins may be restricted by an increase in the saturation index of the membrane, while a decreased index may facilitate contact with reductases for electron transfer by enhanced membrane fluidity. The decreased saturation index after treatment with MC may play a role in carcinogenicity by triggering induction of free radicals.

Predictive modeling techniques in prostate cancer

A number of new predictive modeling techniques have emerged in the past several years. These methods can be used independently or in combination with traditional modeling techniques to produce useful tools for the management of prostate cancer. Investigators should be aware of these techniques and avail themselves of their potentially useful properties. This review outlines selected predictive methods that can be used to develop models that may be useful to patients and clinicians for prostate cancer management.

Genetic adaptive neural network to predict biochemical failure after radical prostatectomy: a multi-institutional study

BACKGROUND AND PURPOSE

Despite many new procedures, radical prostatectomy remains one of the commonest methods of treating clinically localized prostate cancer. Both from the physician's and the patient's point of view, it is important to have objective estimation of the likelihood of recurrence, which forms the foundation for treatment selection for an individual patient. Currently, it is difficult to predict the probability of biochemical recurrence (rising serum prostate specific antigen [PSA] concentration) in an individual patient, and approximately 30% of the patients do experience recurrence. Tools predicting the recurrence will be of immense practical utility in the treatment selection and planning follow up. We have utilized preoperative parameters through a computer based genetic adaptive neural network model to predict recurrence in such patients, which can help primary care physicians and urologists in making management recommendations.

PATIENTS AND METHODS

Fourteen hundred patients who underwent radical prostatectomy at participating institutions form the subjects of this study. Demographic data such as age, race, preoperative PSA, systemic biopsy based staging and Gleason scores were used to construct a neural network model. This model simulated the functioning of a trained human mind and learned from the database. Once trained, it was used to predict the outcomes in new patients.

RESULTS

The patients in this comprehensive database were representative of the average prostate cancer patients as seen in USA. Their mean age was 68.4 years, the mean PSA concentration before surgery was 11.6 ng/mL, and 67% patients had a Gleason sum of 5 to 7. The mean length of follow-up was 41.5 months. Eighty percent of the cancers were clinical stage T2 and 5% T3. In our series, 64% of patients had pathologically organ-confined cancer, 33% positive margins, and 14% had seminal vesicle invasion. Lymph node positive patients were not included in this series. Progression as judged by serum PSA was noted in 30.6%. With entry of a few routinely used parameters, the model could correctly predict recurrence in 76% of the patients in the validation set. The area under the curve was 0.831. The sensitivity was 85%, the specificity 74%, the positive predictive value 77%, and the negative predictive value of 83%.

CONCLUSION

It was possible to predict PSA recurrence with a high accuracy (76%). Physicians desiring objective treatment counseling can use this model, and significant cost savings are anticipated because of appropriate treatment selection and patient-specific follow-up protocols. This technology can be extended to other treatments such as watchful waiting, external-beam radiation, and brachytherapy.