Tag Archive for: minimally invasive surgery

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Article of the week: Cognitive training for technical and non‐technical skills in robotic surgery: a randomised controlled trial

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. There is also a video produced by the authors.

If you only have time to read one article this week, it should be this one.

Cognitive training for technical and non‐technical skills in robotic surgery: a randomised controlled trial

Nicholas Raison* , Kamran Ahmed*, Takashige Abe*, Oliver Brunckhorst*, Giacomo Novara, Nicolo Buf§, Craig McIlhenny, Henk van der Poel**, Mieke van Hemelrijck††, Andrea Gavazzi‡‡ and Prokar Dasgupta*

 

*Division of Transplantation Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, Kings College London, UK, ††Division of Cancer Studies, Kings College London, UK, Department of Urology, Forth Valley Royal Hospital, Larbert, UK, Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan, Department of Urology, University of Padua, Padua, §Department of Urology, Humanitas Clinical and Research Centre, Rozzano, Milan, ‡‡Department of Urology, Azienda USL Toscana Centro, Florence, Italy, and **Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands

 

Visual Abstract created by Rebecca Fisher @beckybeckyfish

Abstract

Objective

To investigate the effectiveness of motor imagery (MI) for technical skill and non‐technical skill (NTS) training in minimally invasive surgery (MIS).

Subjects and Methods

A single‐blind, parallel‐group randomised controlled trial was conducted at the Vattikuti Institute of Robotic Surgery, King’s College London. Novice surgeons were recruited by open invitation in 2015. After basic robotic skills training, participants underwent simple randomisation to either MI training or standard training. All participants completed a robotic urethrovesical anastomosis task within a simulated operating room. In addition to the technical task, participants were required to manage three scripted NTS scenarios. Assessment was performed by five blinded expert surgeons and a NTS expert using validated tools for evaluating technical skills [Global Evaluative Assessment of Robotic Skills (GEARS)] and NTS [Non‐Technical Skills for Surgeons (NOTSS)]. Quality of MI was assessed using a revised Movement Imagery Questionnaire (MIQ).

Results

In all, 33 participants underwent MI training and 29 underwent standard training. Interrater reliability was high, Krippendorff’s α = 0.85. After MI training, the mean (sd) GEARS score was significantly higher than after standard training, at 13.1 (3.25) vs 11.4 (2.97) (P = 0.03). There was no difference in mean NOTSS scores, at 25.8 vs 26.4 (P = 0.77). MI training was successful with significantly higher imagery scores than standard training (mean MIQ score 5.1 vs 4.5, P = 0.04).

Conclusions

Motor imagery is an effective training tool for improving technical skill in MIS even in novice participants. No beneficial effect for NTS was found.

 

From necessity to defining new standards: the new ORSI Academy Campus aims to advance training standards and opportunities for surgical trainees #OrsiNewCampus

ORSI Academy

The sun comes out for the official opening of the new Orsi Academy training campus

 

Orsi Academy (www.orsi-online.com) is a Belgian centre of surgical innovation and expertise where industry, clinical practitioners and academic partners work together on the improvement of best practices in minimally invasive surgery via training, academic research and technological R&D. Orsi Academy continually strives to form inclusive partnerships to further surgical training and improve patient outcomes.

With expert clinicians from around the world, Orsi Academy has a strong history of pioneering peer-to-peer training driven by collaboration with key opinion leaders in the different medical fields. The trainings are validated through academic research and accredited by different scientific bodies (EAU, NASCE, Ugent, KU Leuven). ORSI Academy continually reports and publishes on validated surgical training and the impact on patient outcomes and published the first validated robotic curriculum.

Within the organisation of Orsi Academy there is a rich history of developing and utilising novel training technologies and developing simulation models for dry and wet-lab training. Our aim is to define optimised surgical techniques and to develop models that reflect these defined objective metrics. Examples of this work include 3D printed models, the Venezolan chicken model for Vesico-urethral anastomosis, the dog cadaver for RARP and VR simulation. An example of a successful product launch in VR simulation is the robotic prostatectomy model on the Simbionix ® system that was developed under the guidance of Orsi Academy training staff. At ORSI Academy the first robotic Curriculum was validated on robotic prostatectomy and is now certified by the European Scientific Society EAU (CC-ERUS).  Continuous innovation has helped Orsi Academy maintain a leading market position and the evolved curriculums designed by Orsi Academy are being replicated in training centres of excellence around the world.

Since Orsi Academy’s inception in 2012 it has continued to build on its reputation for training surgeons in new technologies and to continually advance the boundaries of excellence in surgical healthcare. With growing numbers of trainees and courses, capacity became a growing issue and in 2015 ambitious plans were formulated to build a new Orsi campus. The initial plans to rebuild quickly built momentum and planned capacity was further expanded as talks progressed and interest from our supporting partners grew.

 

The new Orsi Academy, planned for September 2018

 

In 2016 the design of the new building was finalised.  The new Orsi Academy facility would contain four 350m² clusters, each housing four to six fully equipped training labs. Two clusters will be equipped for robotic surgery training, the others will be setup for training in other minimally invasive techniques and would include state-of-the-art imaging technologies. The cutting-edge facility would also include an auditorium with the latest audio-visual technologies, where up to 120 people will be able to attend lectures, watch livestreams of surgeries from around the globe, and contribute to discussions and debates in real-time. Additionally, there would be multiple fully equipped meeting rooms and a modern open office set-up would allow all stakeholders to work efficiently, either alone or in small groups. A new inhouse restaurant was planned that would provide meals with soup bar, salad bar, cold dishes and hot meals available.

In February 2017 work commenced and in August 2018 the dream of creating this training centre of excellence was finally realised.

 

On the 18th September Orsi Academy had their official opening of the new campus facilities. The opening ceremony was attended by invited guests, including politicians, representatives of Leuven and Ghent University, surgeons from all over the world and our facilitator for the ceremony a previous Miss Belgium and presenter from Belgian news TV.

 

Alex Mottrie (CEO), Geert Vandenbrouke (Chairman) and Luc Veramme (COO) present at a press conference from the new 120-seat auditorium

 

Press look around the new facilities

 

Some of the guests try out one of the six Da Vinci robots already installed

 

Describing the benefits of simulation training to the press, to introduce new technologies without compromising patient safety

 

Industry presents on why they have supported this project

 

The guests for the opening ceremony begin to arrive and receive their name tags

 

Mingling in the main entrance hall

 

Admiring some of the newly installed artwork

 

Artwork has generously been loaned for both inside and outside the new building

 

Time to chat with the guests

 

The celebration party starts

 

The Orsi Academy training centre has been expanded and upgraded with the support of the European Fund for Regional Development (EFRD), the Flemish Agency of Innovation and Entrepreneurship (VLAIO) and the province of East-Flanders. Additional private funding was provided by the universities of Ghent and Leuven and the medical technology companies Medtronic and Intuitive. Orsi would like to thank industry, the Universities, EU and Flanders funding agencies and all the board for their ongoing support of this educational project. Together we aim to continuously improve standards of training in Europe.

Have you trained at Orsi Academy? If so please post a comment and tell us about your experience and how your career has progressed #OrsiNewCampus

 

Justin Collins, Medical Director Orsi Academy

 

 

 

Light Years Ahead – John Wickham (1927 – 2017)

John Wickham BSc, MB BS, MD, FRCS(Eng), FRCP(Hon), FRCR(Hon), FRSM(Hon)

1927 – 2017

 

 

 

 

The news of the passing of the legendary John Wickham on 26 Oct 2017 will sadden many. Here is a celebration of the life of a visionary thinker, innovator and pioneering surgeon.

Born in Chichester, John moved with his mother to Littlehampton and spent many happy years in rural Sussex. This year he published his book “An Open and Shut case – The story of Keyhole or Minimally Invasive Surgery” which describes his unique journey through life and his passion for reducing the trauma of surgery for the benefit of his patients. A couple of years before this, he sent me the “raw” version to read and comment on. This will forever remain a treasured possession along with a first signed copy of the final version which arrived on my desk in May 2017. A brilliant exercise in honest writing combined with his wry humour.

 

 

 

 

 

 

 

 

 

There were a number of exciting events in his childhood. He describes “epilation radiotherapy” to his scalp to eradicate ringworm which he provides as the explanation for the lack of hair in later life. Such personal touches keep the reader engaged as do his daily travels from Littlehampton to Bart’s (St. Bartholomew’s Hospital), costing £16 per quarter. He was interviewed by Sir William Girling-Ball for his entry into medical school and subsequently worked for Sir Ronald Bodley-Scott, physician to HM the Queen. Time spent in the Royal Air Force (RAF) toughened him up for the complexities of life as a surgeon. 

He was trained in urology by Mr A W Badenoch, another legend in his own right. John describes his first inguinal hernia repair, during which his chief had to leave to take a phone call and he was saved by guidance from the anaesthetist. In his days the pass rate for the FRCS was around 10% and he was one of the lucky ones! He subsequently worked with Prof. Ian Aird of the textbook fame. He met his wife Ann, during a below knee amputation from behind a surgical mask. He was awarded a Fullbright scholarship to Lexington, USA which he thoroughly enjoyed. Despite the offer of a job to stay back, the family decided to return to the UK, where he became a Bart’s man, going on to lead the Department of Urology as its head with Bill Hendry as his colleague.

He was also the Director of the Academic Unit at the Institute of Urology at the then 3Ps (Peter, Paul and Phillips) Hospitals and after the move of St. Peter’s to the Middlesex Hospital. He was also Consultant Urological Surgeon to the King Edward VII Hospital and The London Clinic.

He is credited with a number of pioneering achievements. His device for renal cooling with coils was published in the BJU in 1967. He worked with the famous Sir David Innes Williams and was awarded the Hunterian Professorship. He also published a seminal paper on urethral pressure profile.

Very few will know that he was sidelined with an attack of acute pancreatitis and needed a cholecystectomy for gall stones.

He developed PCNL with Mike Kellett and then the Society and Journal for Minimally Invasive Therapy (SMIT) as well as the Intrarenal Society. He inspired the future generation of great innovators like Graham Watson, Ron Miller and Malcolm Coptcoat, to name a few. With the help of the Kuwait Health Office he managed to instal a Dornier lithotripter in Welbeck street which was revolutionary in those days.

John developed the PROBOT, the first autonomous surgical robot with Prof. Brian Davies at Imperial College. Initially tested in potatoes, it was then refined with the addition of a mapping ultrasound and a vaportome, leading to a world first clinical trial at Guy’s, where he had moved to with the support of Lord Ian McColl. In this project, he was ably helped by Malcolm Coptcoat, Anthony Timoney, Senthil Nathan and Bibhas Kundu. Many years later this device was displayed at a public exhibition at the Royal College of Surgeons of England. It is curious how autonomy is again being discussed amongst roboticists after some 30 years.

Following retirement from the NHS he continued to innovate by establishing a company called Syclix which allowed him to design laparoscopic instruments with pen like grips rather than the traditional handles. He arrived at Guy’s one summers morning to show me these instruments to try on one of my laparoscopic nephrectomy patients. At my request, he examined Ben Challacombe’s thesis on the first ever randomised trial of telerobotics and was then guest of honour at our first robotics symposium in 2004 and the inauguration of the King’s-Vattikuti Institute of Robotic Surgery in 2014.

While clinically active he did his best to spread his philosophy about Minimally Invasive Surgery throughout the world by lecturing and publishing articles in the BMJ, amongst other journals. Many did not believe in him, but he was clearly light years ahead of his time. He received numerous honours, which included the Cheselden Medal and the Galen Medal of the Society of Apothecaries.

It was a privilege to know him and he will remain a lasting inspiration to many.

Prokar Dasgupta

Editor in Chief, BJUI

 

BJUI has published a special Virtual Issue celebrating the legacy and work of John Wickham

 

 

Video: Bimanual Examination Of The Retrieved Specimen And Regional Hypothermia During Robot-Assisted Radical Prostatectomy: A Novel Technique For Reducing Positive Surgical Margin And Achieving Pelvic Cooling

Bimanual examination of the retrieved specimen and regional hypothermia during robot-assisted radical prostatectomy: a novel technique for reducing positive surgical margin and achieving pelvic cooling

Wooju Jeong, Akshay Sood, Khurshid R. Ghani, Dan Pucheril, Jesse D. Sammon, Nilesh S. Gupta*, Mani Menon and James O. Peabody

Vattikuti Urology Institute and *Department of Pathology, Henry Ford Health System, Detroit, MI, USA

Read the full article
OBJECTIVE

To describe a novel method of achieving pelvic hypothermia during robot-assisted radical prostatectomy (RARP) and a modification of technique allowing immediate organ retrieval for intraoperative examination and targeted frozen-section biopsies.

PATIENTS AND METHODS

Intracorporeal cooling and extraction (ICE) consists of a modification of the standard RARP technique with the use of the GelPOINT™ (Applied Medical, Rancho Santa Margarita, CA, USA), a hand access platform, which allows for delivery of ice-slush and rapid specimen extraction without compromising pneumoperitoneum.

RESULTS

The ICE technique reproducibly achieves a temperature of 15 °C in the pelvic cavity with no obvious body temperature change. Adopting this technique during RARP, there was an absolute risk reduction by 26.6% in positive surgical margin rate in patients with pT3a disease when compared with similar patients undergoing conventional RARP (P = 0.04).

CONCLUSIONS

The ICE technique eliminates the potential handicap of decreased tactile sensation for oncological margins, especially in the high-risk patients. This technique allows the surgeon to immediately examine the surgical specimen after resection, and with the aid of frozen-section pathology determine if further resection is required. A prospective trial is underway in our centre to evaluate the effects of this novel technique on postoperative outcomes.

 

Step-by-Step: Robotic kidney transplantation

Robotic kidney transplantation with intraoperative regional hypothermia

Ronney Abaza, Khurshid R. Ghani*, Akshay Sood*, Rajesh Ahlawat†, Ramesh K. Kumar*, Wooju Jeong*, Mahendra Bhandari*, Vijay Kher† and Mani Menon*

Department of Urology, Ohio State University, Columbus, OH, *Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA, and †Kidney and Urology Institute, Medanta-The Medicity, Gurgaon, India

Read the full article
OBJECTIVE

• To describe a novel and reproducible technique of robotic kidney transplantation (RKT) that requires no repositioning, and permits intraoperative regional hypothermia.

PATIENTS AND METHODS

• A GelPOINT™ (Applied Medical, Santa Ranchero, CA, USA) access port was used for delivery of ice-slush and introduction of the graft kidney. The new RKT technique using ice-slush has been performed in 39 patients.

RESULTS

• At a mean follow-up of 3 months all of the grafts functioned. There was a marked reduction in pain and analgesic requirement compared with patients undergoing open KT, with a propensity towards quicker graft recovery and lower complication rate.

CONCLUSION

• RKT has been shown to be safe and feasible in patients undergoing living-donor related KT. A prospective trial is underway to assess outcomes definitively.

 

Article of the week: An open and shut case: outcomes similar for open and robotic prostatectomy

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video of Jonathan Silberstein discussing his paper.

If you only have time to read one article this week, it should be this one.

A case-mix-adjusted comparison of early oncological outcomes of open and robotic prostatectomy performed by experienced high volume surgeons

Jonathan L. Silberstein*, Daniel Su*, Leonard Glickman*, Matthew Kent†, Gal Keren-Paz*, Andrew J. Vickers†, Jonathan A. Coleman*‡, James A. Eastham*‡, Peter T. Scardino*‡ and Vincent P. Laudone*‡

*Department of Surgery, Urology Service, and †Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, and ‡Department of Urology,Weill Cornell Medical Center, New York, NY, USA

Read the full article
OBJECTIVE

• To compare early oncological outcomes of robot assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) performed by high volume surgeons in a contemporary cohort.

METHODS

• We reviewed patients who underwent radical prostatectomy for prostate cancer by high volume surgeons performing RALP or ORP.

• Biochemical recurrence (BCR) was defined as PSA  0.1 ng/mL or PSA  0.05 ng/mL with receipt of additional therapy.

• A Cox regression model was used to evaluate the association between surgical approach and BCR using a predictive model (nomogram) based on preoperative stage, grade, volume of disease and PSA.

• To explore the impact of differences between surgeons, multivariable analyses were repeated using surgeon in place of approach.

RESULTS

• Of 1454 patients included, 961 (66%) underwent ORP and 493 (34%) RALP and there were no important differences in cancer characteristics by group.

• Overall, 68% of patients met National Comprehensive Cancer Network (NCCN) criteria for intermediate or high risk disease and 9% had lymph node involvement. Positive margin rates were 15% for both open and robotic groups.

• In a multivariate model adjusting for preoperative risk there was no significant difference in BCR rates for RALP compared with ORP (hazard ratio 0.88; 95% CI 0.56–1.39; P = 0.6). The interaction term between © 2013 The Authors 206 BJU International © 2013 BJU International | 111, 206–212 | doi:10.1111/j.1464-410X.2012.11638.x Urological Oncology nomogram risk and procedure type was not statistically significant.

• Using NCCN risk group as the covariate in a Cox model gave similar results (hazard ratio 0.74; 95% CI 0.47–1.17; P = 0.2). The interaction term between NCCN risk and procedure type was also non-significant.

• Differences in BCR rates between techniques (4.1% vs 3.3% adjusted risk at 2 years) were smaller than those between surgeons (2.5% to 4.8% adjusted risk at 2 years).

CONCLUSIONS

• In this relatively high risk cohort of patients undergoing radical prostatectomy we found no evidence to suggest that ORP resulted in better early oncological outcomes then RALP.

• Oncological outcome after radical prostatectomy may be driven more by surgeon factors than surgical approach.

 

Read Previous Articles of the Week

Editorial: Oncological outcomes: open vs robotic prostatectomy

John W. Davis and Prokar Dasgupta*

Departments of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA and *Guy’s Hospital, Kings College London, London, UK
e-mail: [email protected]

For men at significant risk of dying from untreated prostate cancer within reasonably estimated remaining life spans, which technique offers the best disease-free survival: open radical prostatectomy (RP) or robot-assisted RP (RARP)? The practice patterns in many countries suggest RARP, but many concerns have been raised about the RARP technique for high-risk disease, including positive surgical margin rates, adequate lymph node dissections (LNDs), and the learning curve. In this issue of the BJUI, Silberstein et al provide a convincing study, short of a randomised trial, that suggests that in experienced hands both techniques can be effective, and that surgeon experience had a stronger effect than technique. In contrast to large population-based studies, this study sought to take the learning curve and low-volume surgeon variables out of the equation by restricting the inclusion criteria to four high-volume surgeons from a single centre. The follow-up is short (one year), and may underestimate the true biochemical relapse rates, and needs follow-up study, but for now offers no difference in relapse rates nor pathological staging outcomes.

Beyond the comparative effectiveness research (CER), Silberstein et al also provide a valuable vision for prostate cancer surgeons using any standard technique. Several recent landmark studies on PSA screening, the Prostate cancer Intervention Versus Observation Trial (PIVOT), and comparisons of metastatic progression between RP and radiation, all indicate the need to shift our practice pattern towards active surveillance for lower risk patients (with or without adjunctive focal therapy, but the former still experimental in our view), and curative therapy for intermediate- to high-risk disease. Such a practice pattern is evident when you compare this study (2007–2010) with a similar effort from this institution (2003–2005) comparing RP with laparoscopic RP (LRP). In the former study, >55% had low-risk disease compared with <35% from the current study. As expected, the present study shows higher N1 stage (9%) and positive surgical margin rates (15%) than the former (7% and 11%, respectively). While erectile function recovery was not presented, the authors noted the familiar reality that patients demand nerve sparing whenever feasible, only 2% in this study had bilateral non-nervesparing and 91% had a combination of bilateral or partial nerve sparing. The number of LNs retrieved has increased from 12–13/case to 15–16, and the authors state that even with nomogram-based exclusion of mandatory pelvic LNDs with <2% risk of N1 staging, this modern cohort had a pelvic LND in 94% of cases, including external iliac, obturator, and hypogastric templates.

We fully concur with this practice pattern, and have recently provided a video-based illustration of how to learn the technique, and early experience showing an increase in median LN counts from eight to 16, and an increase in positive LNs from 7% to 18%. By risk group, our positive-LN rate was 3% for low risk, 9% for intermediate risk, and 39% for high risk. We certainly hope that future multi-institutional studies will no longer reflect what these authors found, in that RARP surgeons are five times more likely to omit pelvic LNDs than open, even for high-risk cancers.

Finally, Silberstein et al and related CER publications leave us the question, does each publication on CER in RP have to be comprehensive (i.e. oncological, functional, and morbidity) or can it focus on one question. Members of this authorship line have published the ‘trifecta’ (disease control, potency, and continence) and others the ‘pentafecta’ (the trifecta plus negative surgical margins and no complications). Indeed, Eastham and Scardino stated in an editorial that ‘data on cancer control, continence, or potency in isolation are not sufficient for decision making and that patients agreeing to RP should be informed of functional results in the context of cancer control’. We feel that the answer should be no, focused manuscripts have their merit and publication space/word limits create this reality. But we should not discount the sometimes surprising results when one institution using the same surgeons and methodologies publishes on the broader topic: the Touijer et al. paper discussed above found the same oncological equivalence between RP and LRP as this comparison of RP and RARP, but also included functional data showing significantly lower recovery of continence with LRP. Nevertheless, the recent body of work in the BJUI now provides a well-rounded picture of modern CER including oncological outcomes, complicationsrecovery of erectile dysfunction, continence and costs. We feel it is reasonable to conclude that patients should be counselled that RARP has potential benefits in terms of blood loss, hospital stay, and complications (at increased costs), but oncological and functional results are probably based upon surgeon experience.

Abbreviations

CER, comparative effectiveness research; LN(D), lymph node dissection; (RA)(L)RP, (robot-assisted) (laparoscopic) radical prostatectomy

Read the full article

Dr Silberstein’s commentary on open vs robotic prostatectomy

A case-mix-adjusted comparison of early oncological outcomes of open and robotic prostatectomy performed by experienced high volume surgeons

Jonathan L. Silberstein*, Daniel Su*, Leonard Glickman*, Matthew Kent†, Gal Keren-Paz*, Andrew J. Vickers†, Jonathan A. Coleman*‡, James A. Eastham*‡, Peter T. Scardino*‡ and Vincent P. Laudone*‡

*Department of Surgery, Urology Service, and †Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, and ‡Department of Urology,Weill Cornell Medical Center, New York, NY, USA

Read the full article
OBJECTIVE

• To compare early oncological outcomes of robot assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) performed by high volume surgeons in a contemporary cohort.

METHODS

• We reviewed patients who underwent radical prostatectomy for prostate cancer by high volume surgeons performing RALP or ORP.

• Biochemical recurrence (BCR) was defined as PSA  0.1 ng/mL or PSA  0.05 ng/mL with receipt of additional therapy.

• A Cox regression model was used to evaluate the association between surgical approach and BCR using a predictive model (nomogram) based on preoperative stage, grade, volume of disease and PSA.

• To explore the impact of differences between surgeons, multivariable analyses were repeated using surgeon in place of approach.

RESULTS

• Of 1454 patients included, 961 (66%) underwent ORP and 493 (34%) RALP and there were no important differences in cancer characteristics by group.

• Overall, 68% of patients met National Comprehensive Cancer Network (NCCN) criteria for intermediate or high risk disease and 9% had lymph node involvement. Positive margin rates were 15% for both open and robotic groups.

• In a multivariate model adjusting for preoperative risk there was no significant difference in BCR rates for RALP compared with ORP (hazard ratio 0.88; 95% CI 0.56–1.39; P = 0.6). The interaction term between © 2013 The Authors 206 BJU International © 2013 BJU International | 111, 206–212 | doi:10.1111/j.1464-410X.2012.11638.x Urological Oncology nomogram risk and procedure type was not statistically significant.

• Using NCCN risk group as the covariate in a Cox model gave similar results (hazard ratio 0.74; 95% CI 0.47–1.17; P = 0.2). The interaction term between NCCN risk and procedure type was also non-significant.

• Differences in BCR rates between techniques (4.1% vs 3.3% adjusted risk at 2 years) were smaller than those between surgeons (2.5% to 4.8% adjusted risk at 2 years).

CONCLUSIONS

• In this relatively high risk cohort of patients undergoing radical prostatectomy we found no evidence to suggest that ORP resulted in better early oncological outcomes then RALP.

• Oncological outcome after radical prostatectomy may be driven more by surgeon factors than surgical approach.

Zero Ischemia Robotic Laser Partial Nephrectomy: Use of the Thulium laser in Renal Cell Carcinoma

We present a technique for zero-ischemia robotic laser partial nephrectomy, which addresses current concerns focusing on renal ischemia during surgery.

 

Authors: Janet Colli, Gregory Mitchell, Benjamin R. Lee

Department of Urology, Tulane University, New Orleans, LA, USA
 
Corresponding Author: Benjamin R. Lee,  Department of Urology, Tulane University, New Orleans, LA, USA. E-mail: [email protected]
 
ABSTRACT

Objective

To describe use of a robotic-assisted laparoscopic partial nephrectomy technique utilizing the thulium laser for tissue welding without clamping the hilar vessels.

Materials and Methods

A Thulium laser at 30W and a 400 micron fiber placed through a robot arm to excise and achieve hemostasis during resection of renal masses. The masses were localized intraoperatively with a 10mm laparoscopic renal ultrasound probe.  At no point during the procedure were the renal hilar vessels clamped. There was minimal blood loss during the operation. Following resection, the base of the tumor resection bed was oversewn with a running 2-0 Vicryl suture and secured with LapraTy clips. The renal capsule was then closed with 0 Vicryl over a Surgicel bolster together with Floseal for an additional degree of hemostasis.

Results

The robotic partial nephrectomies were completed without complication, with complete tumor excision confirmed by negative pathologic surgical margins.  Final pathology demonstrated clear cell cell carcinoma. Patients were discharged on postoperative day 2, and have had no long term complications.

Conclusions

Partial nephrectomy continues to grow in application for treatment of T1 renal cell carcinoma.  We present a technique for zero-ischemia robotic laser partial nephrectomy, which addresses current concerns focusing on renal ischemia during surgery.

INTRODUCTION

Widespread application of laparoscopic and/or robotic assisted partial nephrectomy has been limited by concerns regarding warm and cold ischemia limits during resection as well as technical performance. Currently, there is a lack of reliable means to achieve cold ischemia laparoscopically or robotically , and controversy persists as to the limits of warm ischemia before irreversible nephron death occurs. The ultimate goal is to develop a laparoscopic partial nephrectomy technique which allows bleeding to be controlled during the operation without the need to clamp hilar vessels, hence resulting in zero ischemia time and maximizing nephron preservation.

Over the past decade, several researchers have demonstrated laser partial nephrectomy without the need to clamp the hilar vessels in the animal model [1-3].  In 1998, the Nd:YAG laser was the first to be tested on a series of seven patients with small renal masses during laparoscopic partial nephrectomy without hilar clamping [4].  Since that time, reports have been published detailing operative experience from a series of five patients who underwent laser-supported partial nephrectomies without hilar clamping using open surgical techniques [5]. We describe a robotic assisted laparoscopic partial nephrectomy technique with laser tissue welding using a Thulium laser and robotic arm adaptor to induce parenchymal resection and minimize hemorrhage whereby the vessels are not clamped during resection.  This technique was utilized in the care of two patients at our institution after approval by Tulane’s Institutional Internal Board Review committee.

CASE REPORTS

An incidental solid renal mass was discovered in a 55 year old male during an evaluation for vague abdominal symptoms. CT scan revealed a 2.5 centimeter peripherally located solid, enhancing, left renal mass. In similar circumstances, a left lateral 2cm renal mass was incidentally found in a 62 year old male. Both patients underwent robotic assisted left partial nephrectomies and we share our experience with laser tissue welding and present the salient points of the procedure.

A standard modified flank position with transperitoneal approach was used.  Two 8 mm robotic trocars were placed and two assistant working ports were placed (one 5mm and one 12mm port). Location of the robotic trocars and working ports vary depending on the location of the renal mass (see Figure 1 for illustration of port placements).

Figure 1. Trocar Placement for Robotic Left Partial Nephrectomy

After docking the robot, a 30 degree robotic lens, focused down, was placed in the camera port, the Monopolar scissors were placed in the right robot port and the Prograsp forceps were placed in the left robot port.  The white line of Toldt was incised to expose the retroperitoneum, and the ispilateral colon was reflected medially. The ureter was identified and mobilized from the surrounding tissues, and care taken to not devascularize the ureter. The renal mass was identified and localized with  laparoscopic renal ultrasound.  The capsule around the renal tumor was scored with the bipolar forceps.

Using a Thulium laser at 30 Watts, we resected the renal tumor with a 400 micron fiber placed through a robotic arm.  The wavelength of the Thulium laser system, which is almost identical to the well accepted Holmium laser, is known for its suitability for resection and fragmentation, its safe application in an aqueous medium, and excellent hemostasis. However, in contrast to ruptured cutting edges affected by the “pulsed operation mode of Holmium lasers, the Thulium laser operates in a continuous wave mode and evaporates tissue continuously without generating pressure waves” [6]. The Thulium laser wavelength penetrates tissue to a depth of 0.5mm and provides strong absorption in any kind of tissue and gives access to a wide range of flexible fiber delivery systems [6]. The laser fiber traversed the kidney parenchyma while sealing the tissue and achieving hemostasis. Irrigation was provided through both the robotic arm and the assistant port using an irrigator-aspirator. Smoke was evacuated with the suction device through a 5mm assistant port. No bulldog clamps were placed on the renal hilum during the entire procedure.

There was minimal bleeding during the resection. The collecting system was not entered during the surgery. The base of the tumor resection bed was oversewn with a running 2-0 Vicryl (Ethicon Inc., Somerville, NJ) suture and secured with LapraTy.  The renal capsule was closed with 0 Vicryl over a Surgicel (Ethicon Inc., Somerville, NJ) bolster together with Floseal (Baxter, Deerfield, IL) for an additional degree of hemostasis. A Jackson-Pratt drain was left over the resection bed. The patient was admitted to the hospital wards for routine postoperative care.

The robotic partial nephrectomies were performed without complication. The operative times were 191 and 155 minutes, with a blood loss of 200 mL and 150mL respectively (see Table 1 for patient demographic information).

Table 1. Demographic and laboratory information from patients undergoing unclamped robot-assisted laparoscopic partial nephrectomy

DG JP
Date 10/19/2010 1/13/2011
Tumor Size 1.0 cm 1.1 cm
Tumor Location Mid Pole of Left Kidney Mid Pole of Left Kidney
Pathology Type Clear Cell Polypoid Renal Cell Carcinoma Papillary Renal Cell Carcinoma
Preop Creatinine 0.9 1.3
Preop GFR 66 59
Postop Creatinine Day 1& 2 1.3,     1.1 1.2,     1.0
Postop GFR Day 1 60 64
Operative Time 3h11m (dock time: 2h20m) 2h33m
Length of Hospital Stay 2 days (~52 hours) 2 days (~51 hours)

 
In both cases, postoperative drain output was minimal and abdominal examination demonstrated no clinical evidence of urinoma or delayed hemorrhage. The patients’ hospital courses were uneventful, and they were discharged on postoperative day two.  Follow-up care has been conducted on an outpatient basis.

Histopathologic analysis showed preservation of the renal parenchyma immediately beneath the laser scoring, with final pathology revealing Clear Cell Renal Carcinoma, Fuhrman nuclear grade 1-2/4 with negative margins, stage T1/ N0/M0 and Papillary Renal Cell Carcinoma in the second patient. Tumor excision was complete on all sides and margins were free of cancer (see Figure 2a and 2b).

Figure 2a and 2b. Pathological Photographs

Serum creatinine on postoperative day two= 1.1 (eGFR=73), and 1.0 (respectively) unchanged from that measured preoperatively. Serum hemoglobin and hematocrit remained unaltered during or after the surgery.

DISCUSSION

Recent American Urologic Association guidelines recommend partial nephrectomy for surgical treatment of small, T1 renal masses in order to preserve renal function and minimize cardiovascular comorbidities [7]. Partial nephrectomies are performed with increasing application as the technique has evolved to address previously daunting technical issues such as risk of hemorrhage and development of fistulae postoperatively. Laparoscopic partial nephrectomy (LPN) has been developed to reduce morbidities that occur with the open technique, but LPN requires advanced training to accomplish tumor resection and renal reconstruction while minimizing warm ischemia times. Robotic assistance is able to potentially decrease the learning curve of LPN, largely due to the reconstruction and needle placement afforded provided by the articulation of the robotic arms, the ability to move 180 degrees, and the 3-D vision provided by the binocular laparoscope lens.   Compared to laparoscopic partial nephrectomy, the use of the Davinci robot has been shown to decrease warm ischemia time due to its ability to facilitate the sutured parenchymal reconstruction [8].  However, widespread application of laparoscopic and/or robotic assisted partial nephrectomy has been limited by the lack of a reliable means of instilling ice to attain cold ischemia coupled with limits of warm ischemia during hilar clamping.

A recent study reported  approximately one third of patients who undergo a partial nephrectomy with renal hilar clamping in addition to definable high risk surgical factors and preexisting renal insufficiency go on to develop chronic kidney disease (stage III) [9]. The cause of chronic renal insufficiency in these patients may be related to warm ischemia. Warm ischemia decreases the threshold for ischemic/perfusion injury, which subsequently results in decreased glomerular filtration rate and may be permanent in cases with prolonged warm ischemia time. Ultimately, minimizing warm ischemia time is the most important modifiable factor in limiting kidney injury following partial nephrectomy.

It is not surprising, therefore, that techniques that eliminate the clamping of the renal vessels during partial nephrectomy are continuously sought.  One such recently described technique employs induced hypotension with nadir systemic blood pressure occurring during excision of the deepest portion of a tumor (along with continuous monitoring of a variety of physiological parameters) in order to minimize blood loss during partial nephrectomy with unclamped renal vessels [10].  In contrast, our technique makes use of the unique tissue-welding properties of the Thulium laser to provide hemostasis.  Over the past decade, various lasers have been evaluated as potential hemostatic energy sources during partial nephrectomy [1-3]. The first laser to be tested during an open partial nephrectomy was a CO2 laser used on a canine model in 1972 [11]. This laser was found to have poor hemostatic qualities and its use in kidney surgery was discontinued. The YAG laser was then investigated by Malloy during open partial nephrectomy performed under cold ischemia in a series of six patients with solitary kidneys in 1986 [12].   The Ho: YAG laser was used in the canine model during open partial nephrectomies in 1992, and was found to result in a two-fold reduction in the depth of necrosis when compared to the Nd: YAG laser [13].  Even so, the overall conclusion at that time was that laser dissection offered no advantage over cold ischemia routinely used in the open surgical technique.

In 1998, Janetscheck was the first to use laser tissue welding (Nd:YAG) during laparoscopic partial nephrectomy in a series of seven patients [4]. Over the next ten years, several investigators tested a multitude of lasers and evaluated their ability to coagulate renal tissue during partial nephrectomies in the animal model [14, 15]. In 2001, Lotan demonstrated a laser laparoscopic partial nephrectomy in an unclamped porcine model [14].  Moinzadeh performed laparoscopic partial nephrectomies in a series of six calves in 2005, using a 532nm wavelength laser (KTP Greenlight) [15].  In separate studies, Hindley and Liu further investigated the characteristics and settings of the KTP laser. They found the KTP laser had excellent hemostatic properties; however saline irrigation and smoke evacuation were required to overcome the problem of char build-up and smoke production [16, 17]. In 2007, Anderson examined the KTP laser in the porcine model, and found the setting of 80W was best for tissue cutting and 30W was best for coagulation delivered via a 365 um fiber [18]. The Cleveland clinic examined the Greenlight laser system use in conjunction with a robotic assisted laparoscopic partial nephrectomy. They found hemostasis was problematic throughout the case and also charring of the renal parenchyma obscured the intrarenal dissection and contributed to the focally positive margin [15]. Furthermore, high affinity of the 532 nm wavelength light for hemoglobin resulted in excessive absorption of the laser light with resultant decrease in the cutting efficiency of the laser beam [14].

By 2007, the Thulium laser was approved for use and Bui investigated the 30 Watt laser system delivered via a 365 μm fiber in a porcine model [19]. In 2008, Gruschwitz performed open partial nephrectomies in five patients without hilar clamping using the Thulium laser system [5]. The authors found the thulium laser could coagulate vessels up to 1.5 mm and contributed to short operative times, minimal blood loss and decreased the need for cold ischemia. This technique has an even greater need in laparoscopic and robotic cases in which cold ischemia is difficult to achieve.

We previously reported the technique of laser partial nephrectomy via a transgastric route in the animal model in 2010 [20].  With a controlled gastrotomy through the fundus of the stomach, an endoscope was passed to visualize the upper pole of the left kidney.  The thulium laser was used to resect the upper pole with adequate hemostasis, and specimen extraction with a wire snare.  Closure of the stomach was performed with metal clips.

Recent experimental studies have demonstrated other potential uses of the Thulium laser. Blackmon[21]evaluated the Thulium laser fiber’s capability of vaporizing urinary stones, and found vaporization rates for the Thulium laser averaged 5-10 times higher than for the holmium laser at 70 mJ pulse energies.[21]   Other researchers studied the ability of the Thulium laser to resect prostate tissue.[22]  Xia[22] performed a randomized prospective trial comparing Thulium laser prostatectomy with transurethral prostatectomy, and found equal efficacy of the two techniques and decreased catheterization time, blood loss and hospital stay, in addition to shorter learning curve in favor of the Thulium laser.

One heretofore unmentioned technical challenge we encountered during this study was maintaining optimal visualization during the delivery of irrigation to the laser fiber intraoperatively. The 400 micron laser fiber requires continuous irrigation to diminish debris and char formation on the fiber.  Controversy exists as to the limits of renal injury caused by warm ischemia. Some researchers have shown that limited warm ischemia < 20-30 minutes is transient and irreversible [23], while recent studies have demonstrated that any amount of ischemia has adverse effects on the kidney over time [24]; and efforts to minimize (or eliminate) warm ischemia should be performed. While performing a partial nephrectomy with an unclamped hilum leads to zero ischemia, it can often produce significant bleeding, leading to poor visualization and rendering precise renal surgery difficult. Application of laser techniques to control bleeding was able to allow resection and completion of the partial nephrectomy with zero ischemia during our case series.

CONCLUSIONS

We present a technique of laser tissue welding during robotic laparoscopic partial nephrectomy which provided reliable hemostasis without the need to clamp hilar vessels. Performance of the surgery without having to clamp the renal vessels resulted in zero ischemia time and therefore optimal preservation of renal function. In addition to successfully controlling bleeding (without hilar clamping), this technique protected the underlying parenchyma from the deleterious effect of coagulation. Furthermore, pathologic evaluation showed preservation of the renal parenchyma immediately below the laser incision with preserved ability to identify staging, grading and margin status. This technique demonstrates that the Thulium laser probe can be used for both cutting renal parenchyma while providing adequate hemostasis.

This new approach provides an exciting option that may be applied in selected cases of laparoscopic or robotic partial nephrectomies. Further studies need to be conducted to identify if this technique can be applied to larger and endophytic renal tumors.

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Acknowledgement:  Photographs in Image 1 were supplied by Tulane Department of Pathology ( Dr. Sharon Hirsh)

Date added to bjui.org: 05/01/2012

DOI: 10.1002/BJUIw-2011-064-web

 

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