Best of AUA 2013: Minimally Invasive Surgery

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Presented by James Brown, MD

University of Iowa, Iowa City

• In a review of the 2009-2010 Nationwide Inpatient Sample, robot-assisted vaginal vault suspension was used in 52% of cases due to lower length of stay, lower transfusion rates, and postoperative complications that are equivalent to the open technique.

• Researchers reviewing an FDA database for the years 2009-2010 found an overall adverse event rate for the da Vinci robot (Intuitive Surgical, Inc.) of 0.1%, 27% of which were urology cases. A significantly greater adverse event severity was seen than what should be expected for the type of device used.

• Robotic surgery using the da Vinci Si and da Vinci standard surgical system was associated with a 6.6% positioning injury rate, which included shoulder pain, hand and thigh paresthesias, and arm weakness. Operative time, positioning of the upper extremity on an arm board away from the trunk, American Society of Anesthesiologists score, and amount of intravenous fluid infused were significantly associated with injuries.

• The year 2008 saw an explosion of minimally invasive surgeries far exceeding the robustness of publications to support the techniques.

• In patients undergoing robot-assisted radical prostatectomy (RARP), prior transurethral resection of the prostate increased positive surgical margin rate by 10% and was also associated with worse urinary leakage at 1 month post-op and weakness of urinary stream. Separately, at 18 months post-RARP, numerous EPIC (Expanded Prostate Cancer Index Composite for Clinical Practice) continence outcomes were negatively associated with higher OR time. However, SHIM (Sexual Health Inventory for Men) score was not associated with longer OR time or blood loss.

• A urethral Foley catheter is tolerated as well as a suprapubic tube after RARP.

• Hypothermia is associated with lower inflammation rates and a corresponding improvement in continence in RARP patients.

• A new technology that monitors the nerves innervating the levator ani in real time demonstrates promise in improving continence after robot-assisted laparoscopic prostatectomy.

• Positive surgical margins greater than 3 mm in length or multifocality of margins in RARP patients are independent predictors of biochemical recurrence.

• Researchers shared the first report of biochemical control among patients undergoing robotic prostatectomy with standard pelvic lymph node dissection (33% event-free survival at 3 years).

• Salvage RARP is safe and feasible. Separately, researchers found that the procedure can be performed in patients with body mass index higher than 40. Two additional groups reported that patients taking aspirin or aspirin plus clopidogrel (Plavix) seemed to have very solid outcomes with only longer length of stays and a slightly higher transfusion rate.

• Robotic partial nephrectomy (PN) has passed laparoscopic PN as the most common minimally invasive approach for PN. Robotic PN surpasses the open technique in virtually all fields except hospital charges, which are significantly higher after the robotic procedure. A separate group reported that robotic surgical outcomes are superior to laparoscopic and similar to open PN.

• Among studies that reviewed the use of near-infrared fluorescence (NIRF) with indocyanine green, two groups reported an approximately 80% agreement between histology and NIRF behavior. Interestingly, this technology is also helpful in identifying strictures. A 10% sterile milk solution showed a thousand-fold enhancement advantage for seeing this technology.

• Two studies found that zero-ischemia robotic/laparoscopic partial nephrectomy yields short-term renal function advantages. Two other studies, however, found that at approximately 14 months and 2 years, respectively, the early advantage in renal function was lost and the function was similar between the cohorts.

• Several groups reported equal outcomes for laparoscopic single-site surgery (LESS) and standard laparoscopic surgery. Only one group reported cosmetic benefits with LESS. Another group reported that magnetic tracking of technology of LESS surgeons’ ergonomics demonstrated that their joints are in a non-optimal positions compared with standard laparoscopy. This supports Dr. S. Duke Herrell’s claim at a plenary panel discussion that micro laparoscopy with 3-mm instruments may be a better alternative to LESS.

• A patient-specific simulator for laparoscopic renal surgery has been successfully developed. Three different surgeons felt the simulator provided good to very good results in anatomic integrity, efficacy of simulation, and the sense of security for the upcoming operation.

• A novel telesurgical system with haptic sensation shows promise.

• Researchers using Surgicel plugs for trocar port closure during laparoscopic/robotic surgery had no hernias in 500 cases.

• Endoscopic inguinofemoral lymphadenopathy nearly eliminates wound complications compared with the open technique, although it has a longer operative time.

• Robotic radical cystectomy is no better than open radical cystectomy. Patients in each cohort had similar complications, positive lymph node rates, positive surgical margin rates, and the same length of stay. OR time was 2 hours longer for the robotic procedure, and there was 160 mL more blood loss for the open technique. Two other groups found fairly similar outcomes, pointing to the relevant equivalence of these two techniques.UT

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