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Tuderti G, Mastroianni R, Anceschi U, Bove AM, Brassetti A, Ferriero M, Misuraca L, Flammia RS, Proietti F, D'Annunzio S, Leonardo C, Guaglianone S, Anselmi M, Zampa A, Torregiani G, Gallucci M, Simone G. Learning curve for intracorporeal robotic Padua ileal bladder: 10-year functional assessment from a high-volume single-centre series. BJU Int 2024. [PMID: 38459659 DOI: 10.1111/bju.16328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
OBJECTIVES To assess the impact of the learning curve (LC) on perioperative and long-term functional outcomes of a consecutive single-centre series of robot-assisted radical cystectomy with Padua intracorporeal orthotopic neobladder. PATIENTS AND METHODS Patients treated between 2013 and 2022 were included, with ≥1 year of follow-up. The entire cohort was divided in tertiles. Categorical and continuous variables were compared. Joinpoint regression analysis was used to identify significant changes over the decade in linear slope of the 1-year day- and night-time continence. Uni- and multivariable Cox regression analyses identified predictors of day- and night-time continence recovery. Day-time continence was defined as 'totally dry' (no pads), night-time continence as pad wetness ≤50 mL (one safety pad). RESULTS Overall, 200 patients were included. The mean hospital stay (P = 0.002) and 30-day complications (P = 0.04) significantly reduced over time; the LC significantly impacted on Trifecta achievement (P < 0.001). The 1-year day- and night-time continence probabilities displayed a significant improving trend (day-time continence annual average percentage change [AAPC] 11.45%, P < 0.001; night-time continence AAPC 10.05%, P = 0.009). The LC was an independent predictor of day- (hazard ratio [HR] 1.008; P < 0.001) and night-time continence (HR 1.004; P = 0.03) over time. CONCLUSION Patients at the beginning of the LC had significantly longer hospitalisations, more postoperative complications, and lower Trifecta rates. At the 10-year analyses, we observed a significant improving trend for both the 1-year day- and night-time continence probabilities, highlighting the crucial role of the LC. However, we are unable to assess the case volume needed to achieve a plateau in terms of day- and night-time continence rates.
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Affiliation(s)
- Gabriele Tuderti
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Riccardo Mastroianni
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Umberto Anceschi
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Alfredo Maria Bove
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Aldo Brassetti
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | | | - Leonardo Misuraca
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Rocco Simone Flammia
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Flavia Proietti
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Simone D'Annunzio
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Costantino Leonardo
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | | | - Marianna Anselmi
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Ashanti Zampa
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Giulia Torregiani
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Michele Gallucci
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, IRCCS 'Regina Elena' National Cancer Institute, Rome, Italy
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Kostakopoulos N, Bellos T, Malovrouvas E, Katsimperis S, Kostakopoulos A. Robot-Assisted Urological Oncology Procedures, Outcomes, and Safety in Frail Patients: A Narrative Review of Available Studies. Urol Res Pract 2024; 50:36-41. [PMID: 38451128 PMCID: PMC11059976 DOI: 10.5152/tud.2024.23198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/18/2023] [Indexed: 03/08/2024]
Abstract
In this study, we assess the impact of frailty on the success rate and risk of complications of robot-assisted urological procedures and introduce effective preoperative screening tools to evaluate frail patients' fitness to tolerate robot-assisted urological surgery. We performed a search of electronic databases for available studies, published up to August 2023, investigating the outcomes of robot-assisted urological oncology procedures and their safety in frail patients. Sixteen studies were ultimately selected, investigating the implications of frailty in robot-assisted radical cystectomy, robotassisted partial nephrectomy, and robot-assisted radical prostatectomy. All the studies used the Clavien-Dindo classification of complications with serious complications considered as Clavien-Dindo 3. Frail patients significantly benefit from robot-assisted urological procedures in comparison to open surgery, with lower rates of blood transfusion and a shorter length of stay. However, they also have a higher risk of postoperative complications than non-frail patients, as well as increased rates of conversion to open, total hospital costs, and in-hospital mortality after robot-assisted procedures. Robot-assisted urological procedures can improve the postoperative recovery of frail patients in comparison to open surgery. Reliable frailty indexes such as the Johns Hopkins indicator and simplified frailty index, as well as the Geriatric 8 screening tool, should be routinely used in the preoperative assessment of frail patients to optimize surgical decision-making.
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Affiliation(s)
- Nikolaos Kostakopoulos
- Department of Urology, Metropolitan General, Athens, Greece
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen Urology Unit, NHS Grampian, United Kingdom
| | - Themistoklis Bellos
- Department of Urology, University of Athens, Sismanogleio General Hospital, Athens, Greece
| | | | - Stamatios Katsimperis
- Department of Urology, University of Athens, Sismanogleio General Hospital, Athens, Greece
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Guliev BG, Komyakov BK, Bolokotov RR, Al-Attar TK. [Robot-assisted radical cystectomy with neobladder formation]. Urologiia 2020:54-60. [PMID: 33185348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder formation is a complex surgical procedure. AIM To describe the main stages of RARC and to analyze its short-term results. MATERIALS AND METHODS RARC with ileocystoplasty was performed in 16 patients, most of whom were men (n=14). In 15 patients, the indication for surgery was bladder cancer (BCa), while one patient has radiation-induced sigmoid fistula with a formation of small, contracted bladder. During radical cystectomy (RC), the lower ureters were dissected, followed by posterior dissection of the bladder with mobilization from both sides to the pelvic fascia, clipping and transection of the vesical pedicles, and suturing of the dorsal venous complex with urethral dissection. After pelvic lymph node dissection, 40 cm of the ileum was resected, after that two distal segments of 15 cm were U-shaped, and a 1.5 cm incision was made in the lower part of the bowel, followed by a formation of the urethral anastomosis. Then bowel segments were detubularized, and continuous suture on the posterior and anterior walls of the neobladder was done. Ureters were implanted in the proximal tubular part of the resected colon according to the Nesbit technique. RESULTS The mean operation time was 380 minutes. The blood loss ranged from 80 to 200 ml; however, blood transfusion was not performed. Complications during 30-days after RARC were observed in 7 (43.7%) patients, including 4 (25%) of class I-II according to Clavien - Dindo, and 3 (18.7%) of class III-IV. In patients with leakage at the uretero- intestinal anastomosis (n=2) and urethro-neobladder anastomosis (n=1), percutaneous drainage was performed, which allowed to resolve these complications. There were no cases of bowel obstruction. One patient with gastrointestinal bleeding required blood transfusion. The 90-day late complications occurred in 6 (37.5%) patients, including 2 cases of upper urinary tract infection. One patient died of acute myocardial infarction. CONCLUSION RARC is a contemporary minimally invasive method for muscle-invasive BCa. Stepwise approach to RARC with intracorporeal neobladder formation may reduce the operation time and the rate of complications.
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Affiliation(s)
- B G Guliev
- Department of urology of North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
- Center of Urology with robot-assisted surgery of City Mariinsky hospital, Saint Petersburg, Russia
| | - B K Komyakov
- Department of urology of North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
| | - R R Bolokotov
- Department of urology of North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
- Center of Urology with robot-assisted surgery of City Mariinsky hospital, Saint Petersburg, Russia
| | - T Kh Al-Attar
- Department of urology of North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
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Abstract
The da Vinci single port surgical system (SP) is the newest iteration of robotic technology, which combines the camera and all instruments into a single port. Robotic assisted radical cystectomy (RARC) with intracorporeal urinary diversion has classically been a difficult operation. Here we describe our technique for RARC with the SP and review our initial outcomes and data in the literature. Four patients at our institution underwent single port robotic assisted radical cystectomy with intracorporeal ileal conduit using the da Vinci SP surgical system. Operative steps were performed as described. Perioperative outcomes were reviewed. All patients successfully underwent the procedure without intraoperative complications. The average operative time was 270 minutes with an EBL of 250 cc. The average nodal harvest was 12.5. The average length of stay was 5.5 days. There was one 30-day Clavien Grade II complication and no additional 90-day complications. With our initial experience with the da Vinci surgical system, radical cystectomy with intracorporeal urinary diversion can be performed safely and quickly with the right technique. Our outcomes are similar to other initially published data. Further study is necessary to determine the additional benefits and clinical outcomes.
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Affiliation(s)
- Michael Zhang
- Department of Urology, New York Medical College, Valhalla, NY, USA
| | | | - George Salama
- Department of Urology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Mutahar Ahmed
- The Center for Bladder Cancer at Hackensack University Medical Center, Hackensack, NJ, USA
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Canda AE, Asil E, Koc E, Aldemir M, Ardicoglu A, Atmaca AF. Robotic management of a duplicated ureter during intracoporeal urinary diversion following robotic cystectomy. Cent European J Urol 2017; 70:321-322. [PMID: 29123922 PMCID: PMC5656370 DOI: 10.5173/ceju.2017.1421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/02/2017] [Accepted: 08/02/2017] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Erem Asil
- Ankara Ataturk Training and Research Hospital, Department of Urology, Ankara, Turkey
| | - Erdem Koc
- Ankara Ataturk Training and Research Hospital, Department of Urology, Ankara, Turkey
| | - Mustafa Aldemir
- Ankara Ataturk Training and Research Hospital, Department of Urology, Ankara, Turkey
| | - Arslan Ardicoglu
- Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training and Research Hospital, Department of Urology, Ankara, Turkey
| | - Ali Fuat Atmaca
- Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training and Research Hospital, Department of Urology, Ankara, Turkey
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Abstract
Robot-assisted (RA) procedures are increasingly being performed as minimally invasive surgical approaches. Less insensible losses due to a closed abdomen, smaller incisions with less retractor strain, decreased analgesic requirements, and earlier postoperative ambulation are suggested advantages of robot-assisted radical cystectomy (RARC). Patients who undergo open radical cystectomy are also candidates for RARC procedure. However, the steep Trendelenburg position and pneumoperitoneum develop a non-physiological condition. Intra-abdominal adhesions preventing the placement of the ports and patients who cannot tolerate the pneumoperitoneum and/or steep Trendelenburg position are special contraindications of RARC. Besides, body mass index >30 kg/m2, presence of extravesical disease, bulky lymphadenopathy, previous vascular surgery, previous distal colorectal surgery, previous pelvic radiation, previous pelvic trauma, and/or preexisting cardiovascular/pulmonary disease that is compromised with positioning are not certainly contraindicated but unwanted conditions in which the RARC may be performed successfully as the surgeons gain experience.
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Affiliation(s)
| | - Erdem Koc
- Department of Urology, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
| | - Abdullah Erdem Canda
- Department of Urology, School of Medicine, Ankara Ataturk Training and Research Hospital, Yildirim Beyazit University, Ankara, Turkey
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Attalla K, Kent M, Waingankar N, Mehrazin R. Robotic-assisted radical cystectomy versus open radical cystectomy for management of bladder cancer: review of literature and randomized trials. Future Oncol 2017. [PMID: 28650267 DOI: 10.2217/fon-2017-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Among the many milestones in the last several decades in the management of muscle-invasive bladder cancer and high-risk nonmuscle-invasive bladder cancer including the extension of the standard lymph node dissection and the use of neoadjuvant chemotherapy, minimally invasive techniques have gained traction as an attractive option for radical cystectomy. Open radical cystectomy is plagued with high rates of perioperative and postoperative morbidity and mortality, and as robotic assistance has demonstrated benefits in other arenas of surgery and urology, the evolution of the approach to radical cystectomy has likewise incorporated robotic assistance. We thus sought to critically review the literature comparing open radical cystectomy with robotic-assisted radical cystectomy. Perioperative and oncologic outcomes as well as cost analyses and health-related quality of life were compared between the two approaches, and identified manuscripts were categorized according to level of evidence.
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Affiliation(s)
- Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Marissa Kent
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
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Collins JW, Sooriakumaran P, Sanchez-Salas R, Ahonen R, Nyberg T, Wiklund NP, Hosseini A. Robot-assisted radical cystectomy with intracorporeal neobladder diversion: The Karolinska experience. Indian J Urol 2014; 30:307-13. [PMID: 25097318 PMCID: PMC4120219 DOI: 10.4103/0970-1591.134251] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Introduction: The aim of this report is to describe our surgical technique of totally intracorporeal robotic assisted radical cystectomy (RARC) with neobladder formation. Materials and Methods: Between December 2003 and March 2013, a total of 147 patients (118 male, 29 female) underwent totally intracorporeal RARC for urinary bladder cancer. We also performed a systematic search of Medline, Embase and PubMed databases using the terms RARC, robotic cystectomy, robot-assisted, totally intracorporeal RARC, intracorporeal neobladder, intracorporeal urinary diversion, oncological outcomes, functional outcomes, and complication rates. Results: The mean age of our patients was 64 years (range 37-87). On surgical pathology 47% had pT1 or less disease, 27% had pT2, 16% had pT3 and 10% had pT4. The mean number of lymph nodes removed was 21 (range 0-60). 24% of patients had lymph node positive dAQ1isease. Positive surgical margins occurred in 6 cases (4%). Mean follow-up was 31 months (range 4-115 months). Two patients (1.4%) died within 90 days of their operation. Using Kaplan-Meier analysis, overall survival and cancer specific survival at 60 months was 68% and 69.6%, respectively. 80 patients (54%) received a continent diversion with totally intracorporeal neobladder formation. In the neobladder subgroup median total operating time was 420 minutes (range 265-760). Daytime continence and satisfactory sexual function or potency at 12 months ranged between 70-90% in both men and women. Conclusions: Our experience with totally intracorporeal RARC demonstrates acceptable oncological and functional outcomes that suggest this is a viable alternative to open radical cystectomy.
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Affiliation(s)
- Justin W Collins
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - P Sooriakumaran
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden ; Department of Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - R Sanchez-Salas
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - R Ahonen
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - T Nyberg
- Department of Oncology and Pathology, Section of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - N P Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - A Hosseini
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
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Collins JW, Tyritzis S, Nyberg T, Schumacher MC, Laurin O, Adding C, Jonsson M, Khazaeli D, Steineck G, Wiklund P, Hosseini A. Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder - what is the effect of the learning curve on outcomes? BJU Int 2013; 113:100-7. [PMID: 24053710 DOI: 10.1111/bju.12347] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the effect of the learning curve on operative, postoperative, and pathological outcomes of the first 67 totally intracorporeal robot-assisted radical cystectomies (RARCs) with neobladders performed by two lead surgeons at Karolinska University Hospital. PATIENTS AND METHODS Between December 2003 and October 2012, 67 patients (61 men and six women) underwent RARC with orthotopic urinary diversion by two main surgeons. Data were collected prospectively on patient demographics, peri- and postoperative outcomes including operation times, conversion rates, blood loss, complication rates, pathological data and length of stay (LOS) for these 67 consecutive patients. The two surgeons operated on 47 and 20 patients, respectively. The patients were divided into sequential groups of 10 in each individual surgeon's series and assessed for effect of the learning curve. RESULTS Patient demographics and clinical characteristics were similar in both surgeons' groups. The overall total operation times trended down in both surgeons' series from a median time of 565 min in the first group of 10 cases, to a median of 345 min in the last group for surgeon A (P < 0.001) and 413 to 385 min for surgeon B (not statistically significant). Risk of conversion to open surgery also decreased with a 30% conversion rate in the first group to zero in latter groups (P < 0.01). Overall complications decreased as the learning curve progressed from 70% in the first group to 30% in the later groups (P < 0.05), although major complications were not statistically different when compared between the groups. Patient demographics did not change over time. The mean estimated blood loss was unchanged across groups with increasing experience. The pathological staging, mean total lymph node yield and number of positive margins were also unchanged across groups. There was a decrease in LOS from a mean of 19 days in the first group to a mean (range) of 9 (4-78) days in the later groups, although the median LOS was unchanged and therefore not statistically significant. CONCLUSIONS Totally intracorporeal RARC with intracorporeal neobladder is a complex procedure, but it can be performed safely, with a structured approach, at a high-volume established robotic surgery centre without compromising perioperative and pathological outcomes during the learning curve for surgeons. An experienced robotic team and mentor can impact the learning curve of a new surgeon in the same centre resulting in decreased operation times early in their personal series, reducing conversion rates and complication rates.
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Affiliation(s)
- Justin W Collins
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
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