NOVEL ROBOTIC PLATFORMS FOR ROBOT ASSISTED LAPAROSCOPIC SURGERY IN UROLOGY: A NARRATIVE REVIEW

Robot-assisted surgery (RAS) has been integrated into clinical practice to overcome several limitations of conventional open or laparoscopic surgery. After the expiration of the long key patent period of Intuitive Surgical, various robotic systems (RSs) have been developed aiming at improving certain characteristics of the first robotic platform, the Da Vinci RS. This narrative review provides an overview of the current RSs utilized in urology along with the initial results from their application in urologic procedures. Nine robotic platforms are being analyzed regarding their unique characteristics as well as their efficacy, safety, feasibility, and outcomes in urologic, oncological or non-oncological operations. The main barrier to the wide application of RAS has been the increased cost which refers to both acquisition and maintenance costs. Besides, the health inequality resulting from the lack of expert robotic surgeons and the difficulty of performing robot-assisted procedures in provincial hospitals should be overcome. However, large properly designed comparative studies are required to establish the role of newly introduced RSs. Additionally, urologists should keep abreast of new developments and research in robot-assisted urologic procedures.

How long do we need to reach sufficient expertise with the avatera® robotic system?

PURPOSE

To investigate the learning curve in four basic surgical skills in laparoscopic and robotic surgeries, and evaluate the approximate time needed to reach sufficient expertise in performing these tasks with the avatera® system.

METHODS

Twenty urology residents with no previous experience in dry-lab and robotic surgery were asked to complete four basic laparoscopic tasks (peg transfer, circle cutting, needle guidance, and suturing) laparoscopically and robotically. All participants were asked to complete the tasks first after watching the Uroweb educational material and, second, after undertaking a 2-hour training in robotic and laparoscopic dry-lab. Thereafter, all trainees continued to undertake 2-hour training programs until being able to complete the tasks with the avatera® robot at the desired time. Paired t test and one-way ANOVA test were used to analyze time differences between the groups.

RESULTS

Time needed to complete all tasks either robotically or laparoscopically was significantly less in the second compared to the first attempt for all Groups in each Task. In the robotic dry-lab, time needed to complete the tasks was significantly less than in the laparoscopic dry-lab. A significant effect of previous laparoscopic experience of the participants on the training time needed to achieve most of the goal times was detected.

CONCLUSION

The results of the study highlight the role of previous laparoscopic experience in the training time needed to achieve the performance time goals and demonstrate that the learning curve of basic surgical skills using the avatera® system is steeper than the laparoscopic one.

IDEAL-D Phase 0 Evaluation of the Avatera System in Robot-Assisted Prostate, Bladder and Renal Surgery

Purpose: To evaluate the utilization of novel Avatera system in urological operations according to the IDEAL-D framework recommendations for high-risk invasive surgical devices. Materials and Methods: Three surgeons attempted to perform 23 upper and lower urinary tract operations on human cadavers and in live porcine models using the Avatera system. Total operative time and the duration of the substeps were evaluated. Surgical performance was assessed with the Global Evaluative Assessment of Robotic Skills (GEARS) score. Suturing was rated using the technical checklist for the assessment of suturing in robotic surgery. Attending surgeons rated their satisfaction with the Avatera system on a scale of 1-5. Results and Limitation: Seventeen out of 18 operations performed on cadavers were completed, while one pyeloplasty was discontinued. All five operations performed in porcine models were completed. Although 1 pig was euthanized on the fifth postoperative day, its symptoms were unrelated to surgery. Mean GEARS and Suturing scores in the upper urinary tract were 29 ± 0.7 and 29.5 ± 0.95, respectively, and in the lower urinary 28.5 ± 1.2 and 29.5 ± 0.5, respectively. Surgeons' satisfaction was high or very high for all procedures. Conclusions: The Avatera system was associated with good surgical performance and high surgeons' satisfaction rates. All urological procedures performed were shown to be feasible, with comparable risks to other robot-assisted surgery systems.

Endoscopic enucleation of the prostate with Thulium Fiber Laser (ThuFLEP). A retrospective single-center study

PURPOSE

The aim of the present, retrospective study was to describe our initial experience and early outcomes of Thulium Fiber Laser enucleation of the prostate (ThuFLEP) with the use of the FiberDust™ (Quanta System, Samarate, Italy) in patients with benign prostate hyperplasia.

METHODS

From June 2022 to April 2023, all patients who underwent endoscopic enucleation of the prostate at Urology Department of the University Hospital of Patras were included. A single surgeon utilizing the same standardized operative technique performed all the surgeries. The primary endpoints included the uneventful completion of the operation, the surgical time and any minor or major complication observed intra- or post-operatively.

RESULTS

Twenty patients with benign prostate hyperplasia were treated with ThuFLEP. All the surgeries were completed successfully and uneventfully. The enucleation phase of the operation was completed in a mean time of 45±9.1 min, while the average time needed for the morcellation was 17.65±3.42 min. No significant complications were observed intra- or post-operatively. The average hemoglobin drop was calculated to be 0.94±0.71 g/dL.

CONCLUSIONS

All the operations were successfully and efficiently completed with the use of the FiberDust™ (Quanta System, Samarate, Italy) in ThuFLEP. Significant blood loss or major complications were not observed.

Robot-assisted radical prostatectomy using the avatera system™: a prospective pilot study

BACKGROUND

Robot-assisted radical prostatectomy is a minimally invasive, safe procedure preferred in the management of localized prostate cancer. In this study, we present our initial experience with the avatera™ system (avateramedical GmbH, Jena, Germany) in robot-assisted radical prostatectomy.

METHODS

A total of fourteen patients underwent robot-assisted radical prostatectomy using this newly introduced system in our department from June 2022 to October 2022. The primary endpoints of the study were the time and the successful completion of the operation, the hemoglobin drop and the presence of complications. The pathologic tumor stage and the presence of positive surgical margins were also recorded. Follow-up of the patients for the functional outcomes over a period of 3 months took place.

RESULTS

The completion of all the surgeries was successful. The median draping and docking times were 9.5 minutes (7-13) and 10 minutes (5-40), respectively. The median console time was 103.5 minutes (90-121). No conversion to laparoscopic or open prostatectomy was necessary. The median hemoglobin drop was 1.95 g/dL (0.3-2.7), while positive surgical margins were present in two patients postoperatively. No major complications or need for transfusion were noticed. Six months after the procedure, 78.6% of the participants were continent while 77.7% of the nerve-sparing patients reported erections adequate for intercourse.

CONCLUSIONS

All the operations were completed successfully without major complications or significant blood loss. The functional outcomes were acceptable according to the literature. Based on the early outcomes, robot-assisted radical prostatectomy with the avatera™ system (avateramedical GmbH) could be considered feasible, safe, and efficient.

Nonpapillary Prone Endoscopic Combined Intrarenal Surgery (ECIRS): Five-Year Experience and Outcomes from a High-Volume Center

Endoscopic combined intrarenal surgery (ECIRS) provides simultaneous retrograde and percutaneous access to the upper urinary tract. The purpose of this study is to present revised data, tips and tricks, and technique modifications arising from our five-year experience with ECIRS. The data of 62 patients who underwent nonpapillary prone ECIRS from January 2019 to November 2023 were prospectively collected. All cases were performed in the prone position. Inclusion criteria were complex stone cases with stones in multiple calyces requiring either multiple accesses or multiple sessions to achieve stone-free status. Patients' mean age was 54.4 ± 12.39 years, while the mean stone size was 39.03 ± 13.93 mm. The mean operative time was 51.23 ± 17.75 min. Primary and final stone-free rates were 83.8% and 90.3%, respectively. In total, nine patients presented with postoperative complications, which were all Grade II ones. The holmium-YAG laser type during retrograde lithotripsy was associated with significantly shorter operative times compared to the thulium fiber laser. Nonpapillary prone ECIRS is a feasible, safe, and efficient approach for patients with specific stone and anatomy characteristics. The implementation of more, higher-evidence studies is of utmost importance so that safer conclusions can be drawn.

Replicating Florence Intracorporeal Neobladder Technique in Laparoscopic Radical Cystectomy: A Retrospective Study

OBJECTIVE

To evaluate retrospectively the feasibility of Florence robotic intracorporeal neobladder technique in laparoscopic radical cystectomy.

METHODS

Fourteen patients with muscle-invasive bladder cancer underwent laparoscopic radical cystectomy and Florence robotic intracorporeal neobladder between September 2021 and February 2023. Patients' characteristics, pathology data, perioperative outcomes, postoperative complications, and follow-up data were collected.

RESULTS

All operations were successfully completed laparoscopically. The median total operative time was 343 minutes, and the median estimated blood loss was 169.5 mL. No intraoperative complications were observed. The median hospitalization time was 7days, while the median time to regular diet was 3days. Clavien Dindo Grade < III complications appeared in five patients within 30days postoperation. No other complications were noted over the 90days follow-up. Organ-confined disease was confirmed in 11 patients and locally advanced disease in three patients. At 3months follow-up, eight and four patients were daytime and night-time continent, respectively.

CONCLUSION

Replicating Florence robotic intracorporeal neobladder in laparoscopic radical cystectomy is safe, feasible, and repeatable, based on the encouraging perioperative, oncological, and functional outcomes of our study. However, further prospective studies on a larger scale are required to prove its long-term results.

Feasibility study of a novel robotic system for transperitoneal partial nephrectomy: An in vivo experimental animal study

PURPOSE

To evaluate the safety and feasibility of partial nephrectomy with the use of the novel robotic system in an in vivo animal model.

METHODS

Right partial nephrectomy was performed in female pigs by a surgical team consisting of one surgeon and one bedside assistant. Both were experienced in laparoscopic surgery and trained in the use of the novel robotic system. The partial nephrectomies were performed using four trocars (three trocars for the robotic arms and one as an assistant trocar). The completion of the operations, set-up time, operation time, warm ischemia time (WIT) and complication events were recorded. The decrease in all variables between the first and last operation was calculated.

RESULTS

In total, eight partial nephrectomies were performed in eight female pigs. All operations were successfully completed. The median set-up time was 19.5 (range, 15-30) minutes, while the estimated median operative time was 80.5 minutes (range, 59-114). The median WIT was 23.5 minutes (range, 17-32) and intra- or postoperative complications were not observed. All variables decreased in consecutive operations. More precisely, the decrease in the set-up time was calculated to 15 minutes between the first and third attempts. The operative time was reduced by 55 minutes between the first and last operation, while the WIT was decreased by 15 minutes during the consecutive attempts. No complications were noticed in any operation.

CONCLUSIONS

Using the newly introduced robotic system, all the advantages of robotic surgery are optimized and incorporated, and partial nephrectomies can be performed in a safe and effective manner.

Robot-assisted pyeloplasty for ureteropelvic junction obstruction: initial experience with the novel avatera system

PURPOSE

This pilot study was designed to interpret the technically specific features of the avatera robotic system and present our initial experience with this novel platform in robot-assisted pyeloplasty (RAP).

METHODS

A single-center prospective study was conducted including all patients who underwent RAP with the avatera robotic system from June 2022 to October 2022 in our Department. Transperitoneal robot-assisted dismembered pyeloplasty was performed in all cases. The trocar placement and the surgical technique were similar in all patients. The successful completion of the procedures, operation time (including draping, docking and console time), decrease in hemoglobin postoperatively, and presence of any complications were the study's primary endpoints.

RESULTS

In total, nine patients underwent RAP using the avatera system. All procedures were successfully completed. The draping of the robotic unit was completed in a median time of 10 min (range 7-15), while the median docking time was 17 min (range 10-24). The median console time was 88 min (range 78-116) and no complications were noticed. The median hemoglobin drop was calculated to 0.7 g/dL (range 0.4-1). During the mean follow-up of 9.33 ± 2.78 months, no late postoperative complications were noticed.

CONCLUSION

The early outcomes of the use of the novel avatera system in RAP are presented. All operations were successfully completed with safety and efficacy, without complications or significant blood loss.

Percutaneous trans-hepatic bilateral biliary stenting in Bismuth IV malignant obstruction

AIM

To investigate the clinical efficiency of percutaneous trans-hepatic bilateral biliary metallic stenting for the management of Bismuth IV malignant obstructive disease.

METHODS

Our hospital's database was searched for all patients suffering from the inoperable malignant biliary obstruction Bismuth IV, and treated with percutaneous bilateral trans-hepatic placement of self-expandable nitinol stents. The indication for percutaneous stenting was an inoperable, malignant, symptomatic, biliary obstruction. An un-correctable coagulation disorder was the only absolute contra-indication for treatment. Bismuth grading was performed using magnetic resonance cholangiopancreatography. Computed tomography evaluation of the lesion and the dilatation status of the biliary tree was always performed prior to the procedure. All procedures were performed under conscious sedation. A single trans-hepatic track technique was preferred (T-configuration stenting) and a second, contra-lateral trans-hepatic track (Y-configuration stenting) was used only in cases of inability to access the contra-lateral lobe using a single track technique. The study's primary endpoints were clinical success, defined as a decrease in bilirubin levels within 10 d and patient survival rates. Secondary endpoints included peri-procedural complications, primary and secondary patency rates.

RESULTS

A total of 35 patients (18 female, 51.4%) with a mean age 69 ± 13 years (range 33-88) were included in the study. The procedures were performed between March 2000 and June 2008 and mean time follow-up was 13.5 ± 22.0 mo (range 0-96). The underlying malignant disease was cholangiocarcinoma (n = 10), hepatocellular carcinoma (n = 9), pancreatic carcinoma (n = 5), gastric cancer (n = 2), bile duct tumor (n = 2), colorectal cancer (n = 2), gallbladder carcinoma (n = 2), lung cancer (n = 1), breast cancer (n = 1) or non-Hodgkin lymphoma (n = 1). In all cases, various self-expandable bare metal stents with diameters ranging from 7 to 10 mm were used. Stents were placed in Y-configuration in 24/35 cases (68.6%) using two stents in 12/24 patients and three stents in 12/24 cases (50%). A T-configuration stent placement was performed in 11/35 patients (31.4%), using two stents in 4/11 cases (36.4%) and three stents in 7/11 cases (63.6%). Follow-up was available in all patients (35/35). Patient survival ranged from 0 to 1763 d and the mean survival time was 168 d. Clinical success rate was 77.1% (27/35 cases), and peri-procedural mortality rate was 5.7% (2/35 patients). Biliary re-obstruction due to stent occlusion occurred in 25.7% of the cases (9/35 patients), while in 7/11 (63.6%) one additional percutaneous re-intervention due to stent occlusion resulting in clinical relapse of symptomatology was successfully performed. In the remaining 4/11 patients (36.4%) more than 1 additional reintervention was performed. The median decrease of total serum bilirubin was 60.5% and occurred in 81.8% of the cases (27/33 patients). The median primary and secondary patency was 105 (range 0-719) and 181 d (range 5-1763), respectively. According to the Kaplan-Meyer survival analysis, the estimated survival rate was 73.5%, 47.1% and 26.1% at 1, 6 and 12 mo respectively, while the 8-year survival rate was 4.9%. Major and minor complication rates were 5.7% (2/35 patients) and 17.1% (6/35 patients), respectively.

CONCLUSION

Percutaneous bilateral biliary stenting is a safe and clinically effective palliative approach in patients suffering from Bismuth IV malignant obstruction.

Vegetative state and minimally conscious state: a review of the therapeutic interventions

BACKGROUND/AIMS

The purpose of the present article is a systematic review of the proposed medical or surgical treatments in patients in chronic vegetative state (VS) or minimally conscious state (MCS), as well as of their mechanisms of action and limitations.

METHODS

For this review, we have agreed to include patients in VS or MCS having persisted for over 6 months in posttraumatic cases, and over 3 months in nontraumatic cases, before the time of intervention. Searches were independently conducted by 2 investigators between May 2009 and September 2009 in the following databases: Medline, Web of Science and the Cochrane Library. The electronic search was complemented by cross-checking the references of all relevant articles. Overall, 16 papers were eligible for this systematic review.

RESULTS

According to the 16 eligible studies, medical management by dopaminergic agents (levodopa, amantadine), zolpidem and median nerve stimulation, or surgical management by deep brain stimulation, extradural cortical stimulation, spinal cord stimulation and intrathecal baclofen have shown to improve the level of consciousness in certain cases.

CONCLUSION

The treatments proposed for disorders of consciousness have not yet gained the level of 'evidence-based treatments'; moreover, the studies to date have led to inconclusiveness. The published therapeutic responses must be substantiated by further clinical studies of sound methodology.

Neuropsychological functioning in buprenorphine maintained patients versus abstinent heroin abusers on naltrexone hydrochloride therapy

RATIONALE

Methadone and buprenorphine are among the most widely employed pharmacological treatments currently available for opioid addiction. Cognitive effects of buprenorphine in abstinent heroin abusers are nevertheless far from being understood.

METHODS

Neuropsychological performance of 18 buprenorphine-maintained patients (BMP) was evaluated relative to that of 32 currently abstinent heroin abusers on naltrexone hydrochloride therapy (FHAN), and 34 non-drug dependent controls. The three groups were demographically balanced. Clinical groups reported histories of similar patterns of drug use and had increased periods of abstinence from any illicit substance use including heroin.

RESULTS

The BMP group performed poorer than controls on the RAVLT (encoding and delayed recall of verbal information), CTT (conceptual flexibility, executive functions) and the RBANS figure copy (visual perception) and delayed recall of visual information. There were no significant differences in any of the cognitive measures between the BMP and FHAN groups or between the FHAN group and controls. Furthermore, the non-differing percentage of abnormal cases between the two patient groups led us to infer that treatment with either BPM or FHAN is not accompanied by qualitative differences in the cognitive profiles of these patients.

CONCLUSION

Overall, results suggest that treatment with naltrexone in abstinent heroin abusers may result in less impairment of cognitive functions compared to treatment with buprenorphine. These findings are relevant for improved prognosis and treatment strategies in opioid dependence.

Protective effect of doxycycline use on coronary artery disease?

OBJECTIVES

The potential role of Chlamydia pneumoniae infection in the pathogenesis of atherosclerosis has received increasing attention. The present study was conducted to test the hypothesis that use of doxycycline in doses prescribed in routine clinical practice for brucellosis, decreases the risk of coronary artery disease (CAD).

METHODS

A general practice (GP) database in Western Greece was used. One hundred and twenty-nine newly diagnosed patients with coronary artery disease from 2001 to 2003 were contrasted to 196 controls randomly selected from the same practice. General practice records were reviewed to confirm a diagnosis of incident CAD event and obtain information on other cardiovascular risk factors. CAD events were defined as: Stable/unstable angina, acute myocardial infarction or ischemic death.

RESULTS

The results indicate a significant association between doxycycline use and occurrence of CAD (OR: 0.37, 95% CI: 0.17-0.78).

CONCLUSIONS

These results persisted when adjustment for potential confounding factors was made. The findings should be interpreted cautiously because of lack of information about C. pneumoniae infection. However, the results suggest directions for future epidemiologic studies in this relatively uncharted field.