Robotic cystectomy: its time has come

Perioperative morbidity of radical cystectomy: A review

A systematic review of the literature on perioperative morbidity (POM) was done using Medline software with a combination of keywords like mortality, morbidity, and complications. In addition, we review the analysis of our hospital data of 261 Radical cystectomies (RCs) performed in an 11-year period and our latest clinical pathway for RC. Age range in our series was 50 to 81 years with 240 males and 21 females. RCs were performed by intraperitoneal method in 172 patients and by our extraperitoneal (EP) method in 89 patients. Urinary diversion was ileal conduit in 159 patients and neobladder in 102 patients. Blood loss ranged between 500 and 1500 ccs. Postoperative mortality occurred in eight patients (3%). Among the other early post-op complications, major urinary leak was seen in nine and minor in 11, requiring PCN in five patients and reoperation in four patients. Bowel leak or obstruction was seen in six and four patients, respectively, requiring reoperation in six patients. EP RC in our series showed some benefit in reduction of POM. The mortality of RC has declined but the POM still ranges from 11 to 68%, as reported in 23 series (1999-2008) comprising of 14 076 patients. Various risk factors leading to POM and some corrective measures are discussed in detail. However, most of these series are retrospective and lack standard complication reporting, which limits the comparison of outcomes. Various modifications in open surgical technique and laparoscopic and Robotic approaches are aimed at reduction in mortality and POM of RC.

Transperineal laparoscopy: a new approach

PURPOSE

We describe and evaluate a new transperineal laparoscopic approach for male patients, designed to facilitate laparoscopic prostatectomy and cystectomy.

PATIENTS AND METHODS

We operated on 12 patients. We did three laparoscopic prostatectomies and nine laparoscopic cystectomies. On five, an ileal conduit was made, and on the other four, an orthotopic bladder was constructed. An incision was made in the perineum. A space was bluntly created between the rectum and the prostate. A cannula was then introduced up to the Douglas pouch, which was opened to enter the peritoneal cavity.

RESULTS

One patient of the three prostatectomies needed incontinence pads. None of the four orthotopic bladder cases presented daytime incontinence. The urethra of one of the patients who had an ileal conduit was injured. No other significant complications occurred.

CONCLUSION

Transperineal laparoscopy in male patients is a feasible technique that may be an alternative for natural orifice translumenal endoscopic surgery in women, but further assessment is required.

Differences in grip forces among various robotic instruments and da Vinci surgical platforms

INTRODUCTION

The da Vinci surgical platform is becoming increasingly available and utilized. Due to the lack of haptic feedback, visual cues are necessary to estimate grip forces and tissue tensions during surgery. We directly measured the grip forces of robotic EndoWrist instruments using the three available da Vinci robotic surgical platforms.

METHODS

Robotic instruments were tested in the da Vinci S, Si, and Standard systems. A load cell was placed in a housing unit that allowed for measurement of the grip forces applied by the tip of each robotic instrument. Each instrument was tested six times, and all data were analyzed using Student's t-tests or analysis of variance when appropriate.

RESULTS

Slight differences in grip force were seen when the instrument was tested through 2 degrees of freedom at the tip (p = 0.02, analysis of variance) and when comparing a new instrument to an older instrument (p = 0.001 at the neutral position). There was no statistical difference in grip force between the left and right robotic arms. There was a broad range of grip forces between the various robotic instruments. The lowest grip force was registered in the double fenestrated grasper (2.26 ± 0.15 N), whereas the highest was seen in the Hem-o-lok clip applier (39.92 ± 0.89 N). In comparison to the S and Si, the Standard platform appeared to have significantly higher grip forces.

CONCLUSION

Different grip forces were observed among the various robotic instruments commonly used during urologic surgery and between the Standard and the S and Si platforms.