Laparoscopy Today

Nicholson Center Grand Opening - New Center Prepared to Train 20,000 Clinicians a Year in the Latest Robotic and MIS Techniques

With an all new 54,000 square foot training facility the Florida Hospital Nicholson Center for Surgical Advancement is designed to host major medical training and educational events. It is expected that the center will be used to train about 20,000 clinicians per year in the latest robotic and mininally invasive surgical techniques. The center is designed for face to face events as well as distance learning in remote locations. Visit www.nicholsoncenter.com to learn more about the center and to take the tour of the new facililty.

A Critical Appraisal of Robotic Surgery in Light of Current Experience presented in the Turkish - German Gynecology Congress

by Cihat ÜNLÜ

President of the Turkish - German Gynecological Foundation 

The integration of robotic surgery for routine use in gynecological surgeries, its advantages, disadvantages and cumulating experience on complications was one of the hot topics at the IX Congress of the Turkish German Gynecological Foundation held in Antalya-Turkey, May 4 - 8, 2011. Robotic assisted minimally invasive surgery has the potential to revolutionize the existing standards of the gynecological surgical procedures, especially the oncological interventions, both by greatly reducing postoperative morbidity and by preservation of the radicality and principles of oncological surgery.

FROM THE 18th SLS ANNUAL MEETING: MULTIDISCIPLINARY PLENARY SESSION CANCER AND LAPAROSCOPY

The Role of Robotics in Gynecologic Oncology: the Good, the Bad, and the Ugly presented by Farr Nezhat, MD

The robot has many advantages. It is 3-dimensional, tremor filtration, intuitive movement, 90-degree articulation, and fewer assistants are needed. However, it does have disadvantages.

JOURNAL WATCH: SURG ENDOSC

A Lifelike Patient Simulator for Teaching Robotic Colorectal Surgery: How to Acquire Skills for Robotic Rectal Dissection. Marecik SJ et al. 2008;22:1876-1881 • The authors report on the creation and use of a cost-effective, portable, and reusable model for training in robotic rectal dissection. Various components were included or added to the device depending on the procedure being simulted, but the basis of the tool is a plastic model of the human pelvic skeleton mounted onto a sturdy laminate-covered base using an adjustable bracket to alter the pelvic angle. The authors concluded that the trainer provided an accurate simulation of true robotic rectal dissection.

Evolution of Fetal Surgery

FROM THE 16TH SLS ANNUAL MEETING AND ENDO EXPO 2007, SAN FRANCISCO, CALIFORNIA, SEPTEMBER 5–8, 2007

PRESENTED BY JOSEPH BRUNER, MD

The types of fetal surgeries being performed are growing. The first in utero surgery was bladder open fetal surgery for lower urinary tract obstruction (LUTO). Liver surgery has been performed, as has congenital high airway obstruction (CHAOS) surgery. PLUG, plug the lung until it grows, is a new method for treating congenital diaphragmatic hernias. A flexible endoscope is inserted in the mouth of the fetus, and a balloon is passed through the throat then expanded to open the lungs. The balloon is popped and the baby expels it. Congenital cystic adenomatoid malformation (of the lung) (CCAM) surgery is also being performed; however, sometimes the fetuses die before they heal. Sacrococcygeal teratoma, congenital germ cell tumor arising from the presacral area, surgery is being performed too, but it has a mortality rate of 30% to 50% because it is difficult to occlude vessels to prevent huge blood loss when the tumor is resected and it is hard to tell where the tumor ends and the fetus begins. Intrauterine therapy has also been performed for nonlethal disorders, such as spina bifida. The da Vinci robot has been used in the sheep model for intrauterine surgery, with all robotic surgeries being performed satisfactorily. Although fetal surgery is promising, it is not without problems. For example, all pregnancies need to be performed by cesarian delivery because of the port holes, the working space is small, it is difficult to work in a gas or liquid environment, fetal positioning, port size, and membrane damage.

CONFERENCE REPORT: Robotic Surgery

COMPUTER ENHANCED "ROBOTIC" SURGERY

WILLIAM E. KELLEY, JR, MD

The FDA approved the first computer-enhanced surgical system for abdominal and pelvic laparoscopic surgery in 2000. In 2003 and 2004 robot-assisted mitral valve replacement and robot-assisted CABG were approved. Computerized surgery provides enhanced precision, flexibility, and the ability to deliver highly functional instruments to small awkward locations. It is superior to MIS.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Conversion From Open to Robotic-Assisted Radical Prostatectomy Is Associated With a Reduction in Positive Surgical Margins Among Private Practice-Based Urologists

FROM THE 15TH INTERNATIONAL CONGRESS AND ENDO EXPO 2006, SLS ANNUAL MEETING, BOSTON, MASS, SEPTEMBER 6–9, 2006

RALPH MADEB, DRAGAN GOLIJANIN, CRAIG NICHOLSON, JOY KNOPF, KELLY PICONE, FREDERICK TONETTI, JOHN R. VALVO, LOUIS EICHEL

INTRODUCTION: Several recent studies have suggested that leaders in robotic surgery have decreased their own positive margin rates by switching from open to robot-assisted radical prostatectomy. Theoretically, this improvement is largely attributed to enhanced visualization of the deep pelvis and precision of dissection afforded by the instrumentation. To date, it has not been determined whether this phenomenon exists among nonfellowship-trained urologists in private practice. Herein, we describe the positive margin rates of 2 nonfellowship-trained private practice urologists who converted from open radical retropubic prostatectomy to robot-assisted laparoscopic radical prostatectomy.

METHODS: The margin positivity data from 2 nonfellowship-trained, private practice urologists (surgeon 1 and surgeon 2) were reviewed retrospectively. The last 50 cases of open radical retropubic prostatectomy from each surgeon were compared with the first 50 and 43 robotic prostatectomy cases of surgeons 1 and 2, respectively. A positive surgical margin was defined as a tumor present at the inked margin of the prostate.

RESULTS: A significant decrease occurred in the overall and pT2 positive margin rates for both surgeons. The overall positive margin rate and pT2 positive margin rate for surgeon 1 dropped from 44% to 20% and from 37% to 5.7%, respectively, after changing from open to robotic prostatectomy. For surgeon 2, the overall positive margin rate changed from 26% to 16% and the pT2 positive margin rate changed from 27.5% to 8% after converting.

CONCLUSION: Changing from open to robotic-assisted radical prostatectomy may improve the ability of urologists to obtain negative surgical margins. This phenomenon does seem to apply to nonfellowship-trained urologists in private practice and can be realized within the first 50 cases performed.

For additional information about SLS programs for residents, including the Outstanding Laparoendoscopic Resident Award, scholarships to SLS conferences, and special membership rates, visit www.Laparoscopy.org. 

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

CONFERENCE REPORT: Urology Laparoscopic and Robotic Surgery Update

FROM THE 15TH INTERNATIONAL CONGRESS AND ENDO EXPO

LAPAROSCOPY UPDATE: UROLOGY COMMITTEE

HOWARD N. WINFIELD, MD

Since 1990, urologic surgeons have taken a leading role in minimally invasive surgery (MIS). Laparoscopic radical nephrectomy, first described in 1991, is now considered the “gold standard” for localized renal tumors. Laparoscopic partial nephrectomy for renal masses ≤ 4 cm is gaining increasing popularity. However, this procedure continues to present significant challenges requiring laparoscopic suture repair of the surgical defect, hilar control of renal vessels to minimize hemorrhage and concern for warm ischemic damage to the remaining renal parenchyma. Renal cooling and hemostatic techniques are in evolution to overcome these obstacles. Encouraging long term results (>5 years) are maturing to demonstrate the effectiveness of laparoscopic cryoablation and radiofrequency ablation for the treatment of small renal masses.  Laparoscopic radical prostatectomy is more popular in Europe, and radical cystectomy is performed in select centers in the United States with promising results.

Robotic surgery has found major applications in the field of Urology. Radical prostatectomy (RRP) is the most frequently performed robotic procedure, outstripping all other surgical disciplines. In 2002 there were only 600 robotic prostatectomies performed whereas in 2004 there were 9600 cases reported. This exponential growth is expected to continue.  Oncologic effectiveness, urinary continence, and erectile function are very comparable with open surgery.  The blood loss and convalescence appear to be superior with robotic RRP. Robotic-assisted pyeloplasty for ureteropelvic junction has gained popularity with excellent results comparable to open or laparoscopic pyeloplasty. Robotic radical cystectomy is performed in select centers with encouraging results.

Urologists continue to play an active role for surgical training in the form of computer virtual reality simulation, validity testing and core programs in minimally invasive surgery for residents. Improved methods to provide continuing medical education in minimally invasive surgery for urologists has become an important focus of the American Urological Association.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

CONFERENCE REPORT: Robotic Surgical Innovations in Minimally Invasive Surgery

FROM THE 14TH INTERNATIONAL CONGRESS AND ENDO EXPO

LAPAROSCOPY UPDATE: FUTURE TECHNOLOGIES COMMITTEE

DMITRY OLEYNIKOV, MD

Laparoscopy has been a tremendous advantage for patients as well as physicians over the past ten years. The new revolution however is even more exciting. It is one of robotics. Today we live in a digital age. Our music is digital, our data is digital. However, the interactions with our patients are still in analog. We look at x-rays that are obtained from conventional radiation sources, and we still have to reach out and physically examine our patients. With the invention of surgical robotics, this is changing. The new devices that are available today are to some extent fantastic as they allow us to perform surgeries across oceans while sitting comfortably in a recliner chair. Surgical systems such as the da Vinci Surgical System and the Zeus Surgical System are pioneers in surgical robotics, but these are only the tip of the iceberg. There are a number of companies that are looking to develop new robotic systems, and several companies are researching robotic endoscopes. Olympus is looking at developing active capsule endoscopy. Our own area of interest is miniature robots and we have created a miniature prototype that is a wireless camera and device that allows us to insert a miniature robot into the abdominal cavity of a patient during a laparoscopy. The device is wirelessly driven through the abdominal cavity while at the same time sending video signals. We are now seeking FDA approval of this device for human use. So far it has been used successfully in the animal model. These and other technologies will revolutionize how we treat our patients and change medicine as radically as laparoscopy did more than ten years ago.

Notes

Dr Oleynikov's work with mini-robots has been reported on in the BBC news (http://news.bbc.co.uk; “Dextrous Mini-robots to Aid Ops”); New Scientist (www.newscientist.com; “Robot Set Loose to Film Your Insides”); and MedGadget (www.medgadget.com; “Tiny Robots for Remote Surgery”).

Articles have been published in IEEE Transactions on Robotics, Surgical Innovation, and Journal of Surgical Endoscopy.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Robot-Assisted Radical Prostatectomy: Has the Initial Promise Been Fulfilled?

ROBOTICS

THOMAS E. AHLERING, MD, DOUGLAS W. SKARECKY, BS

The development of a laparoscopic approach to radical prostatectomy has taken several years. Indeed after the initial report of 9 cases, by Schuesler, Clayman, and associates in 1997 [1], 2 to 3 years transpired before meaningful success was described by 2 groups in Paris [2,3]. This is because laparoscopic radical prostatectomy (LRP) is considered the most difficult urological procedure to master due to technical and reconstructive requirements. Although LRP enjoyed sustained growth in Europe, the rather difficult “counterintuitive” nature of the technique retarded its acceptance in the United States.

In 2001, Menon and associates failed to establish a pure LRP program at the Henry Ford Hospital but subsequently fathered the first large-scale robot-assisted LRP program [4]. This group demonstrated that the da Vinci robot (Intuitive Surgical, Inc, Sunnyvale, CA) could overcome the counterintuitive pitfalls of standard LRP surgery. Potential advantages offered by this technology include intuitive instrument handling, 3-D viewing and comfortable ergonomics, precise and facile camera positioning, plus “machine-like” precision with 7 degrees of freedom of the wristed instruments (Figures 1 and 2).

Figure 1. The user-friendly da Vinci robotic console is shown at left, and an example of positioning of the robotic arms is shown at the right of the figure.

Figure 2. Placement of port sites for a 3-arm robotic surgery: L=robot's left arm, R=robot's right arm, C=camera, Q=assistant's left and right hand ports. Reprinted from Urology, Volume 63, Lee et al, Laparoscopic radical prostatectomy with a single assistant, Pages 1172-1175, Copyright 2004 with permission from Elsevier.

However, learning (and training) the technique of robotic (laparoscopic) prostatectomy (RLP) has a substantial learning curve. Several authors have reported that the “4-hour” learning curve is for 15 to 30 cases for experienced open surgeons as reported by Menon [4], Ahlering [5], and Wiklund [6] (Figure 3). The “4-hour” learning curve for LRP has been reported to be 60 to 100 cases. Although the cost of the da Vinci robot (~$1.3 million) and per case expenses favor open and standard laparoscopic surgery, the rapid rise in interest and application of RLP leave little question of its growing acceptance by surgeons and patients. As an experienced open and robotic surgeon, there is no question that the ability to place the tip of the da Vinci 3-D camera between the rectum and prostate 1 cm to 2 cm from the apex and sharply dissect attachments is without parallel in open pelvic surgery. A potential drawback to robotics is the loss of tactile sensation. Some surgeons claim it is an important facet in determining points of extracapsular extension although data supporting the ability to feel a microscopic margin have not been demonstrated.

Figure 3. The learning curve of the UC Irvine experience in achieving 4-hour surgery times with a best-fit curve.  Adapted from Basillotte et al. Laparoscopic radical prostatectomy: review and assessment of an emerging technique. Surg Endosc. 2004:18(12):1694-1711 with kind permission of Springer Science and Business Media

Factors important to both patients and surgeons include operative time, blood loss, transfusion rate, and length of hospital stay, among other things. RLP offers well-established benefits with regard to blood loss, transfusion rate, and length of stay. For example, blood loss was significantly reduced in LRP versus blood loss in open prostatectomy in 2 studies [7,8]. In my own experience, complication rates have been reduced at least 50% (2% to 4% in RLP) compared with complication rates in my open experience (9%). In most published series, complication rates range from 8% to 20% versus 4% to 10% in RLP [9].

ONCOLOGICAL CONTROL

Oncologic outcomes, such as local recurrence or metastatic progression, are primarily driven by individual tumor characteristics like preoperative PSA levels and pathological Gleason score and stage. Obviously, radical prostatectomy cannot change these factors. The primary oncologic goal of radical prostatectomy regardless of approach is to avoid inadvertent entry into the prostate in low-risk patients (pT2 positive margins), and for patients with extracapsular extension the task is to resect soft tissue margins wide enough to prevent pT3 margins. An advantage of RLP is the visual capability afforded by minimal blood loss and intimate camera positioning adjacent to the prostatic capsule. Most experienced robotic centers report in pathologically organ-confined disease (pT2), margin rates ranging from 4.5% to 16% [9,10].

QUALITY OF LIFE ISSUES
Continence

Reporting of continence rates has been needlessly complicated. Continence should be defined as urinary control requiring no pads as determined on self-administered questionnaires. It is a definitive question and when coupled with the time following surgery to achieve pad-free status allows for Kaplan-Meier analysis (Figure 4). Several RP series have reported median time to pad-free status of approximately 35 days to 45 days and a 6-month pad-free status rate of 90% [5,6].  Thanks to the innovative “single knot” urethrovesical anastomosis as described by van Velthoven [11], clinically evident bladder neck contractures in over 500 cases have been below 0.3 % (personal data).

Figure 4. Percentage of men achieving pad-free continence over time.

POTENCY

Like continence, the reporting of potency has a checkered track record. The use of validated questionnaires pre- and postoperatively (eg, IIEF-5 International Index of Erectile Function) is essential to the acquisition of believable data, which can then be used to correlate postoperative erectile function with operative technique [9]. There is no reason to believe that radical prostatectomy (regardless of approach) will make impotent men potent. Historically, the lack of use of validated questionnaires severely hinders evaluation or comparison of sexual function for RP.

In a review of an LRP series by Basilotte et al [9], 47% to 86% of men who were “potent” preoperatively had erectile function adequate for intercourse at 1.5 years of follow-up with or without 5PDE inhibitors. El-Hakim and Tewari [12] summarized the available series on postoperative sexual function in RP. In 4 centers reporting potency, 49.5% of patients had intercourse and 79% had return of erections, with or without 5PDE inhibitors at follow-up of less than 1 year. It is safe to state that definitive conclusions cannot currently be drawn.

Preservation of sexual function from a technical view has 2 components. It is critical to physically preserve the neurovascular bundle (NVB) and also limit thermal or other injury during dissection. RLP initiates the dissection at the prostatic vascular pedicles and proceeds antegrade to dissect the NVB to the apex. Generally, robotic and laparoscopic surgeons use some form of thermal energy to control the vascular pedicles. However, Ong and associates [13] have definitively demonstrated in a laparoscopic dog model the critical need to avoid thermal energy in proximity to the NVB. Although the NVB was “preserved,” thermal injury resulted in a 95% loss of corporal pressures on the involved side. Gill and associates [14] and Ahlering and associates [15] recently described the feasibility of a cautery-free technique to preserve the NVB by using laparoscopic vascular “Bulldog” clamps (Figures 5 and 6). We have already experienced dramatic improvement over our previous technique using bipolar cautery to control the vascular pedicle;16 43% vs. 8% of men (65 years and preoperative IIEF-5 of 22 to 25) have return of erectile function with the cautery-free technique at 3 months with or without 5PDE inhibitors.  Menon et al [17] recently reported potency outcomes at 12 months at either 74% (conventional nerve sparing) and 97% with prostatic fascia preserved (veil of Aphrodite) for prepotent men (IIEF-5) >21 who underwent bilateral nerve sparing. Although the study did not control for bipolar cautery implicated by Ong et al [13], complete information regarding potency will require at least 2 years of follow-up.

Figure 5. Placement of a bulldog clamp on the neurovascular bundle. Reprinted from Urology, Volume 65, Ahlering et al, Feasibility study for robotic radical prostatectomy cautery-free neurovascular bundle preservation, Pages 994-997, Copyright 2005 with permission from Elsevier.

Figure 6. The interoperative placement of a bulldog clamp on the vascular pedicle.  (SV=seminal vesical)

CONCLUSION

In Kuhn's classic description of science, robotic surgery is quickly progressing beyond the prenormative stage of nongeneralized methods and descriptions to a new consensus methodology. The impact of future technological advancements favors the robotic interface and perhaps a new surgical paradigm. Platforms are being explored for preoperative or real-time imaging, or both, of structures (ureters, arteries, nerves, prostatic capsule, and others) for immediate intraoperative feedback. Remote training or proctoring is another promising application. The future may already be evident. In 2001, 247 procedures were performed. In 2002, 2003, 2004, and 2005; 766, 2648, 8642, and 16,000 robotic procedures were performed, respectively. For 2006, the projection is 25,000 of an estimated 100,000 in the United States (personal communication from Intuitive Surgical Inc.). 
 
Figure 7. View of the neurovascular bundle during dissection of the prostate.

Address reprint requests to: Thomas E. Ahlering, MD, Professor of Urology, University of California, Irvine, 101 The City Dr South, Bldg 26, RT 81, Orange, CA 92868, USA. Telephone: 714 456 6703, E-mail: tahlerin@uci.edu

Thomas Ahlering, MD, is Professor and Chief of the Division of Urologic Oncology at the University of California, Irvine. Now in its fifth year of robot-assisted surgery, the UC, Irvine robotic-assisted laparoscopic prostatectomy experience is one of the oldest programs in the world. Dr Ahlering initiated the program and has performed minimally invasive robotic prostatectomies on more than 350 patients and is a recipient of Intuitive Surgical's Pioneer of da Vinci Urology Surgery (2005).

Douglas Skarecky, BS, is a Staff Research Assistant in the Department of Urology at the University of California, Irvine, and has published more than a dozen articles on robotic prostatectomy with Dr. Ahlering.

References

1.    Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR. Laparoscopic radical prostatectomy: initial short-term experience. Urol. 1997;50:854-857.

2.    Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: initial experience and preliminary assessment after 65 operations. Prostate. 1999;39:71-75.

3.    Abbou CC, Salomon L, Hoznek A, et al. Laparoscopic radical prostatectomy: preliminary results. Urol. 2000;55:630-634.

4.    Menon M, Shrivastava A, Tewari A, et al. Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol. 2002;168:945-949.

5.    Ahlering TE, Skarecky DW, Lee DI, Clayman RC. Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with the laparoscopic radical prostatectomy. J Urol. 2003;170: 1738-1741.

6.    Wiklund NP. Technology insight: Surgical robots-expensive toys or the future of urologic surgery? Nature Clinical Practice-Urology. 2004;1:97-102.

7.    Tewari A, Srivasatava A, Menon M, Members of the VIP Team. A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution. BJU Int. 2003;92:205-210.
8.  Ahlering TE, Woo D, Eichel L, et al. Robot assisted vs. open prostatectomy: a comparison of one surgeon's outcomes. Urol. 2004;63:819-822.

9.    Basillotte J, Ahlering TE, Skarecky DW, et al. Laparoscopic radical prostatectomy: review and assessment of an emerging technique. Surg Endosc. 2004;18:1694-1711.

10.    Ahlering TE, Eichel L, Edwards R, et al. Robotic radical prostatectomy: a technique to reduce pT2 margins. Urology. 2004;64:1224-1228.

11.    vanVelthoven R, Ahlering TE, Peltier A, et al. Technique for laparoscopic running urethrovesical anastomosis: “The Single Knot Technique.” Urology. 2003;61:699-702.

12.    El-Hakim A, Tewari A. Robotic prostatectomy- A Review. Medscape General Medicine. 2004;6(4):20.

13.    Ong AM, Su LM, Varkarakis I, et al. Nerve sparing radical prostatectomy: Effects of hemostatic energy sources on the recovery of cavernous nerve function in a canine model. J Urol. 2004;172:1318-1322.

14. Gill IS, Ukimura O, Rubinstein M, et al. Lateral pedicle control during laparoscopic radical prostatectomy: Refined technique. Urology. 2005;65:23-27.

15. Eichel L, Chou D, Skarecky DW, Ahlering TE. Feasibility study for laparoscopic radical prostatectomy cautery free neurovascular bundle preservation. Urology. 2005;65:944-948.

16. Ahlering TE, Eichel L, Skarecky D. Rapid communication: Early potency with cautery free neurovascular bundle preservation with robotic laparoscopic radical prostatectomy. J Endourol. 2005;19(6):715-718.

17. Menon M, Kaul S, Bhandari A, et al. Potency following robotic radical prostatectomy: a questionnaire based analysis of outcomes after conventional nerve sparing and prostatic fascia sparing technique. J Urol. 2005;174:2291-2296.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source