I received a correspondence from intuitive surgical that shows the growth in prostatectomies and hysterectomies (benign and malignant). It describes how there have been over 1.5 million robotic surgeries performed in the last 10 years and the low complication rate.
We found the incidence of concurrent prostate cancer with hernia to be low, but 51% of men had PSA values that suggested an increased relative risk of future development of prostate cancer. Men at increased risk of prostate cancer should be made aware of the impact that mesh might have on subsequent treatment options before mesh placement.
Many years ago it was thought that a prior laparoscopic hernia repair would be a major problem for a patient who had prostate cancer wanted a robotic prostatectomy.
Since 2003 the majority of robotic surgeons have performed robotic surgery through the abdominal cavity. With this approach, the bladder and blood vessels can safely be separated from the mesh with direct visualization.
I do not consider a prior hernia repair with mesh to be a significant concern prior to robotic surgery. The surgery should take a little longer, but removing the prostate is not a significant problem.
The only concern in patients that will undergo hernia repair is to make sure they do not have cancer at the present time. If they do and want surgery for prostate cancer, then a robotic hernia repair and robotic prostatectomy shoudl be done at the same time, avoiding 2 surgeries. I have performed over 100 of these combination hernia repairs and davinci prostatectomies.
I found an abstract about a way to manage urinary ascites that can rarely happen after dvP.
Conventional measures, including catheter traction, passive drainage, and needle vented Foley catheter suction, failed. On postoperative day 6 a unilateral nephroureteral stent was placed on intermittent suction.
Placement of one nephroureteral stent on suction device immediately stopped the urinary anastomotic leakage into the peritoneal cavity.
In case of a persistent urinary leak after RALP that fails conservative management, a nephroureteral stent on suction may aid to stop the anastomotic leak.
I have seen this problem a few times in the past 5 years. The best way to manage it, in my opinion, is to place a drain laparoscopically by the surgeon if one does not exist. I found that interventional radiology does not place as large a drain or in as good a place.
While I am placing the drain laparascopically, I also perform a cystoscopy to attempt to place 5 fr ureteral catheters for urinary diversion. I think the most important thing is to push the foley in away from the bladder neck. I think foley traction on the anastamosis is what keeps the opening open.
We report a large, multi-institutional series of RPN for renal tumors, confirming safety and feasibility reported in previous small, single-institution studies. Although we report the initial experience in RPN at each center, immediate oncologic results and perioperative outcomes approached those of more mature laparoscopic series. Robotic assistance may facilitate the technical challenges of precise tumor resection and renal reconstruction within acceptable warm ischemia times. Long-term outcomes are needed to establish the role of RPN in nephron-sparing surgery.
This was a large multi-institutional study that I was part of. This was the largest robotic partial nephrectomy study reported.
The surgical margins were similar between the two groups. No significant difference was found in the postoperative urinary bother score or the interval to social or perfect continence between the two groups.
The results of this study have shown that the presence of a median lobe does not alter the outcomes in patients who undergo robot-assisted prostatectomy.
The median lobe can be a scary finding for the novice robotic surgeon. My team at NBI has developed several techniques to handle median lobes while preserving as much bladder as possible. Below is a video showing one of our techniques:
I have changed by preoperative management to include a cystoscopy about 1 year ago on all patients to assess for prostate shape. I can now predict these in all patients.
I am a little surprised that these patients did not have differences except more needed bladder neck repairs. I think these patients are more likely to have bladder symptoms since most have obstruction and over active bladders to start with. In my series, they usually get their catheters out in 5 days instead of 3, and I warn them of expecting more urinary problems in the short term than others.
First Annual Worldwide Robotic Renal Symposium
I had the honor of being selected on the faculty for the 1st robotic conference dedicated to kidney surgery. This should be an excellent conference for urologists who are performing robotic surgery for prostate cancer and would like to learn about current techniques for kidney surgery including partial nephrectomy. Transplant surgeons who currently perform laparoscopic donor nephrectomies and would like to learn about robotic surgery are also good candidates.
Eric P. Newman Education Center
Washington University Medical Center – St. Louis, Missouri
Sam B. Bhayani, M.D.
The Division of Urologic Surgery
Washington University School of Medicine
Continuing Medical Education
Information is not adequate to recommend screening men for prostate cancer with digital rectal examination or measurement of prostate-specific antigen (PSA), according to a position statement by the American College of Preventive Medicine (ACPM) published in the February issue of the American Journal of Preventive Medicine.
The American Urological Association recommends that men who are 50 years and older and who have an estimated life expectancy of more than 10 years should be offered PSA screening. The American Cancer Society recommends that men who are 50 years and older and who have a life expectancy of more than 10 years should be offered both DRE and PSA screening. The United States Preventive Services Task Force and American Academy of Family Physicians do not find sufficient evidence to recommend for or against PSA or DRE screening. The Canadian Task Force on Preventive Health Care recommends against routine screening with PSA.
Community urologists who want to learn this must have an adequate volume of cases, at least 20 prostatectomies a year, and it probably will take 20 or 30 procedures before they are comfortable. For someone doing less than 20 cases a year, it doesn’t make much sense. You have to do this procedure with some regularity to keep up your skills.
Pruthi: I hesitate to suggest a number because of the different issues we have mentioned. In the Henry Ford experience, when they looked at complications, the learning curve was 200 cases.
2 At Vanderbilt, the surgeon-reported learning curve was 250 cases.
Laparoscopy has the potential for decreasing surgical morbidity, with smaller incisions, decreased blood loss, less postoperative pain with decreased intake of narcotics, shorter hospital stays, and faster recovery compared with open surgical procedures. While these benefits have been realized for urologic procedures such as nephrectomy, adrenalectomy, and pyeloplasty, technical obstacles have hindered its adoption in more advanced procedures such as prostatectomy.
This is my first technique that I will be adding to a new section of the blog.
After watching many videos and trying different ways to approach an intravesical median lobe, I found a new way to take care of it.
The following video was uploaded to google video and shows the dissection of a median lobe.
In simple terms: The bladder holds the urine and then the urine passes through the prostate on its way out. The prostate needs to be removed completely in prostate cancer surgery. The prostate is separated from the bladder routinely during the operation.
The median lobe is the part of the prostate that sometimes pushes into the bladder. This is the main reason why some urologists elect to place scopes into peoples bladders prior to surgery. This is one of the most difficult parts of the operation for beginners and experienced surgeons. The video shows the prostate (yellow) being separated from the bladder (green). The stitch is placed into part of the prostate to lift it off of the bladder.
Instruments used: PK dissector (bipolar), hot shears (monopolar- setting coag only 30), 2 needle drivers
Suture: 2’0 vicryl on an SH needle. (I have used 0’vicryl on a CT-1 for larger median lobes)
Color scheme- Yellow- Prostate; Green bladder and bladder opening; Orange arrrow- foley