Robotic assisted radical prostatectomy (RARP) has become the commonest minimally invasive surgical procedure for the treatment of localized prostate cancer. Despite limited data supporting the excellence of RARP over laparoscopic radical prostatectomy (LRP) or open radical prostatectomy (ORP), it has gained wide acceptance among the patients and surgeons.
Robotic assisted radical prostatectomy (RARP) has become the commonest minimally invasive surgical procedure for the treatment of localized prostate cancer. Despite limited data supporting the excellence of RARP over laparoscopic radical prostatectomy (LRP) or open radical prostatectomy (ORP), it has gained wide acceptance among the patients and surgeons.
This study aimed to compare the overall and disease specific survivals of patients who underwent laparoscopic and open resection of colorectal cancer in a high volume tertiary center.
This study aimed to compare the overall and disease specific survivals of patients who underwent laparoscopic and open resection of colorectal cancer in a high volume tertiary center.
retroperitoneal tumors esp. retroperitoneal sarcoma is most challenging condition to treat in retroperitoneal region inspite of using all treatment modalities.here is brief description of its management acc. to nccn , and other text book ref.
Invited talk at the 'New Fellows' conference organised by the Royal College of Surgeons of England, Bristol, June 2016. Mr Vasdev shares his fellowship experience being the first accredited Post CCT Fellow in the UK in Robotic Urology by the Royal College of Surgeons of England and British Association of Urological Surgeons
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Robotic prostatectomy – The way forward or is the jury still out ?
1. Robotic prostatectomy –
the way forward or is the jury still out?
Mr Nikhil Vasdev
Post CCT Robotic Urological Fellow
(RCSEng/ BAUS National Accredited Fellowship programme)
Hertfordshire and South Bedfordshire Urological Cancer Centre
Lister Hospital
Stevenage
Dunblane-INVITE_Layout 1 05/09/2013 08:07 Page 1
Faculty in Robotic Urology
Chitra Sethia Robotic Centre
UCL
London
INVITATION
Prostate Cancer
Evening Symposium
3. Introduction
! Men with localized prostate cancer can be offered a radical
prostatectomy
! The types of prostatectomy being offered in the UK
!
!
!
!
Open radical prostatectomy (ORP)
Laparoscopic radical prostatectomy (LRP)
Robotic radical prostatectomy (RRP)
Perineal prostatectomy (RPP)
4.
5. ! Baseline problems in finding evidence for superiority
! A Randomized clinical trial is not feasible because both expert
surgeons and patients have their bias regarding the optimal
technique
! No level 1 evidence
! Different definitions – Positive margins, biochemical recurrence,
urinary incontinence and sexual function
! Limited to single case series, systematic reviews and meta-analysi
! Selection bias in these studies often from high volume, academic
centers
6.
7. Aim
! To evaluate the safety and efficacy of RRP in comparison to
ORP and LRP
RRP
LRP
ORP
Comparative effectiveness research (CER)
8. Aim of prostate cancer surgery
ORP / LRP
RRP
Trifecta
Pentafecta
Disease control
Disease control
Potency
Potency
Continence
Continence
Negative Margins
Complications
9. Objective criteria considered
! Cancer cure rates (In intermediate and high risk groups)
! Positive surgical margin rates
! Urinary continence
! Erectile dysfunction rates
! Peri-operative morbidity
! Post-operative complications
! Costs
10. Nature Reviews Urology 2004
Technology Insight: surgical robots
Expensive toys or the future of urologic
surgery?
‘‘A Robot Saved My Life’’: Is It a Myth?
Premature Robotic Surgery:
Putting Patients and Professionals
at Risk
Robotic Surgery: Hope or Hype?
Presidential Debate SAGES 2011
Will the Future of Health
Care Lead to the End of the
Robotic
Golden Years?
11. Robotic Surgery – Current trend
Robotic technology has been
adopted rapidly over the past 4
years in both the United States
and Europe.
The number of robot-assisted
procedures that are performed
worldwide has nearly tripled
since 2007, from 80,000 to
205,000.
Between 2007 and 2009, the
number of da Vinci
systems75%, from almost 800
to around 1400, and the
number that were installed in
other countries doubled, from
200 to nearly 400
12. da Vinci European Installed Base
1999 – 2012
®
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010-12
17. Surgical disadvantages of
robotic surgery
! Positional injuries and anaesthetic/physiological
repercussions of the steep trendelenburgh position
18. rs). Unadjusted associaented in TABLE 2. Results
y consistent with adtions. In the propensityyses (TABLE 3), men unRP vs RRP experienced
h of stay (median, 2.0 vs
R, 0.67; 95% CI, 0.58ss likely to receive heterfusions (2.7% vs 20.8%;
CI, 0.06-0.17), and were
of postoperative respirations (4.3% vs 6.6%; OR,
I, 0.46-0.87), miscellal complications (4.3% vs
5; 95% CI, 0.56-0.99), and
tricture (5.8% vs 14.0%;
% CI, 0.28-0.52).
men undergoing MIRP vs
ced more genitourinary
(4.7% vs 2.1%; OR, 2.28;
3.22) and were more ofd as having incontinence
function (26.8 vs 19.2 per 100 personyears; OR, 1.4; 95% CI, 1.14-1.72). The
MIRP vs. ORP undergoing Surgery
Figure. Use of Minimally Invasive vs Open
Retropubic Radical Prostatectomy for Men
Diagnosed 2003-2007 in
as Having Prostate Cancer
Radical Prostatectomy, %
2002-2005 and Undergoing Surgery in
2003-2007
100
90
80
70
60
50
40
30
20
10
0
Radical prostatectomy
Minimally invasive
Retropubic
2003
No. of patients
244
Minimally
invasive
Retropubic 2394
usted Outcomes by Surgical Approach
2004
2005
2006-2007
(Combined)
Year of Surgery
542
843
309
2218
1881
406
Hu J et al, JAMA, 2009, Vol 302
19. Oncological Outcomes
! 13 years since the first robotic procedure
! Few centres have follow up of more than 5 years
! Current data indicates that the BCR-free survival estimates
!
!
!
!
95.1% at 1 year
90.6% at 3 years
86.6% at 5 years
81.0% at 7 years
20. Oncological Outcomes
! Badani et al, 7.2% PSA recurrence rate with a 5 year
actuarial biochemical free survival of 84% of this series
! Despite of differences , given the relative follow up for RRP
it is difficult to comment of the superiority of which
technique is better
21. Cancer Control - Selected large RPseries
Technique and series
No of
patients
pT2,%
Overall PSM,
%
BDFS,%
5 year
BDFS,%
10 year
10 year CSS,
%
Han et al
2404
51
11
92
85
96
Roehl et al
3478
61
80
68
97
Chun et al
4277
64.3
21.5
70
61
Guillonneau et al
1000
77.5
19.2
90(3yrs)
Stolzenberg et al
700
55.4
19.8
Lein et al
1000
70.2
26.8
Menon et al
2652
77.7
13
Mottrie et al
184
65.5
15.7
Patel et al
500
78
9.4
Sooriakumaran et al
944
74%
22%
Open RRP
Lap RP
RALP
87%
83%
98%
22. ! Silberstein compared early oncological outcomes of 961
ORP and 493 RRP
! This study is 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 [Data from 4 high volume centres]
! RRP surgeons are five times more likely to omit pelvic LNDs
than open, even for high-risk cancers
23. Positive Surgical Margin
! The presence of a PSM has a significant effect on prostate
cancer progression
! The positive surgical margin rate was 20% for ORP versus
16.7% for RALRP in a study by Ahlering and coworkers
! Smith and colleagues retrospectively reviewed 200
procedures from each approach. The overall incidence of
positive surgical margins was significantly lower among the
RALRP cohort compared with ORP cases (15% vs 35%, P
< .001)
24. Relative effectiveness of robot-assisted and
standard laparoscopic prostatectomy as
alternatives to open radical prostatectomy
for treatment of localised prostate cancer:
a systematic review and mixed treatment
comparison meta-analysis
Clare Robertson, Andrew Close*, Cynthia Fraser, Tara Gurung, Xueli Jia,
Pawana Sharma, Luke Vale†, Craig Ramsay and Robert Pickard‡
Health Services Research Unit, University of Aberdeen, Aberdeen, *School of Biology, †Institute of Health and Society,
and ‡Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, UK
Re-use of this article is permitted in accordance with the Terms and Conditions set out at
http://wileyonlinelibrary.com/onlineopen#OnlineOpen_Terms
Objective
PSM
Robotic Prostatectomy
• To compare the effectiveness of robot-assisted and standard
laparoscopic prostatectomy.
Methods
17.6%
• A care pathway was described.
• We performed a systematic literature review based on a
search of Medline, Medline in Process, Embase, Biosis,
Science Citation Index, Cochrane Controlled Trials Register,
Current Controlled Trials, Clinical Trials, WHO
International Clinical Trials Registry and NIH Reporter, the
Resultslaparoscopic
PSM
Prostatectomy
• We included data from 19 064 men across one RCT and 57
non-randomised comparative reports.
• Robotic prostatectomy had a lower risk of major
intra-operative harms such as organ injury [0.4% robotic vs
2.9% laparoscopic], odds ratio ([OR] {95% credible interval
[CrI]} 0.16 [0.03 to 0.76]), and a lower rate of surgical
margins positive for cancer [17.6% robotic vs 23.6%
laparoscopic], OR [95% CrI] 0.69 [0.51 to 0.96]). There was
no evidence of a difference in the proportion of men with
urinary incontinence at 12 months (OR [95% CrI] 0.55 [0.09
to 2.84]). There were insufficient data on sexual dysfunction.
23.6%
25. New techniques to reduce PSM during
Robotic Prostatectomy
EUROPEAN UROLOGY 62 (2012) 333–340
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Surgery in Motion
Neurovascular Structure-adjacent Frozen-section Examination
(NeuroSAFE) Increases Nerve-sparing Frequency and Reduces
Positive Surgical Margins in Open and Robot-assisted
Laparoscopic Radical Prostatectomy: Experience After 11 069
Consecutive Patients
Thorsten Schlomm a,b,y,*, Pierre Tennstedt a,y, Caroline Huxhold a,y, Thomas Steuber a,
¨us
Georg Salomon a, Uwe Michl a, Hans Heinzer a, Jens Hansen a, Lars Buda a, Stefan Steurer c,
c
c
a
c
Corinna Wittmer , Sarah Minner , Alexander Haese , Guido Sauter , Markus Graefen a,
Hartwig Huland a
26. Nerve-sparing radical
ferenceoftheprostatetodeterminetheSMstatusofthecompleteneurovasculartissuecorresponding prostatic surface.
prostatectomy
NeuroSafe –Outcome measurements and statistical analysis:positiveNeuroSAFE on NS
technique to reduce The impact of
Surgery
surgical marginfrequency, SM status, and biochemical recurrence (BCR) was analyzed by chi-square
during Robotic Prostatectomy
Nerve-sparing
test, and by Kaplan-Meier analyses in propensity score–based matched cohorts.
Frozen section
Results and limitations: Positive SMs (PSMs) were detected in 1368 (25%) NeuroSAFE
RPs, leading to a secondary resection of the ipsilateral neurovascular tissue. Secondary
Surgical margin
wide resection resulted in conversion to a definitive negative SM (NSM) status in 1180
Propensity score
Please visit
www.europeanurology.com and
www.urosource.com to view the
accompanying video.
(86%) patients. In NeuroSAFE RPs, frequency of NS was significantly higher (all stages:
97%vs81%;pT2:99%vs92%;pT3a:94%vs72%;pT3b:88%vs40%;p< 0.0001)andPSM
ratesweresignificantlylower(allstages:15%vs22%;pT2:7%vs12%;pT3a:21%vs32%;
p< 0.0001) than in the matched non-NeuroSAFE RPs. In propensity score–based comparisons,NeuroSAFEhadnonegativeimpactonBCR(pT2,p= 0.06;pT3a,p= 0.17,pT3b,
p= 0.99), and BCR-free survival of patients with conversion to NSM did not differ
significantly from patients with primarily NSM (pT2, p = 0.16; pT3, p = 0.26).
y
27. Our experience with on-table frozen section
! N=14 patients
! Commenced procedure in
November 2012
! All patients were intermediate and
high risk
! All patients had intrafascial nerve
spares
! Our T2 positive margin rates are 0%
from 18%
! Our T3 positive margin rates are
17% from 28%
! Adds a mean of 17 minutes to
operative times
28. Intraoperative outcomes
! Duration of operative time is used as a marker of the
learning curve with RRP
! With time all series have a reduction in the operative times
and console times
! Operative times were shorter in the RRP when compared to
LRP
Operative times Robotic Prostatectomy
Operative times laparoscopic
Prostatectomy
170 +/- 34.2 min
235 +/- 49.9 min
p<0.001
30. Intraoperative Blood loss
! Virtually all published reports confirm a reduction in blood
loss RRP
! The reason for reduced blood loss
! Pneumoperitoneum
! DVC dissection reserved till the end of procedure
32. Late complications
Kowalczyk; EUROPEAN UROLOGY 61 (2012) 803–809
Complication
MIRP n=11108
RRP n=45227
P value
Anastomotic stricture
3%
9.3%
<0.001
Ureteral injury
0.5%
1.3%
<0.001
Recto-urethral fistula
0.4%
0.4%
0.999
Lymphocoele
1.3%
2.2%
<0.001
Surgery for incontinence
0.3%
0.3%
0.734
33. Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Perioperative Outcomes
and Complications After Robot-assisted Radical Prostatectomy
Giacomo Novara a,*, Vincenzo Ficarra a,b, Raymond C. Rosen c, Walter Artibani d,
Anthony Costello e, James A. Eastham f, Markus Graefen g, Giorgio Guazzoni h,
Shahrokh F. Shariat i, Jens-Uwe Stolzenburg j, Hendrik Van Poppel k, Filiberto Zattoni a,
Francesco Montorsi l, Alexandre Mottrie b, Timothy G. Wilson m
• 110 papers evaluating oncologic outcomes following RARP
• Overall mean operative time is 152 min
a
University of Padua, Padua, Italy;
Watertown, MA, USA;
d
b
O.L.V. Robotic Surgery Institute, Aalst, Belgium;
Cancer Center, New York, NY, USA;
g
e
Department of Epidemiology, New England Research Institutes, Inc.,
f
Memorial Sloan-Kettering
Martini-Clinic, Prostate Cancer Centre, University Hamburg-Eppendorf, Hamburg, Germany;
h
University Vita-Salute San
• Mean blood loss is 166 ml
Raffaele, H. San Raffaele-Turro, Milan, Italy;
k
c
Royal Melbourne Hospital, Grattan Street, Melbourne, Australia;
University of Verona, Verona, Italy;
i
Weill Medical College of Cornell University, New York, NY, USA;
University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium;
l
j
University of Leipzig, Leipzig, Germany;
University Vita-Salute San Raffaele, H. San Raffaele, Milan, Italy;
m
City of Hope
National Cancer Center, Duarte, CA, USA
Abstract
• Article infotransfusion rate is 2%
Mean
Article history:
Accepted May 22, 2012
Published online ahead of
print on June 2, 2012
Context: Perioperative complications are a major surgical outcome for radical prostatectomy (RP).
Objective: Evaluate complication rates following robot-assisted RP (RARP), risk factors
for complications after RARP, and surgical techniques to improve complication rates
after RARP. We also performed a cumulative analysis of all studies comparing RARP with
retropubic RP (RRP) or laparoscopic RP (LRP) in terms of perioperative complications.
Evidence acquisition: A systematic review of the literature was performed in August
2011, searching Medline, Embase, and Web of Science databases. A free-text protocol using
the term radical prostatectomy was applied. The following limits were used: humans;
gender (male); and publications dating from January 1, 2008. A cumulative analysis was
conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK).
Evidence synthesis: We retrieved 110 papers evaluating oncologic outcomes following
RARP. Overall mean operative time is 152 min; mean blood loss is 166 ml; mean
transfusion rate is 2%; mean catheterization time is 6.3 d; and mean in-hospital stay
is 1.9 d. The mean complication rate was 9%, with most of the complications being of low
grade. Lymphocele/lymphorrea (3.1%), urine leak (1.8%), and reoperation (1.6%) are the
most prevalent surgical complications. Blood loss (weighted mean difference: 582.77;
• Mean catheterization time is 6.3 d
• Keywords: in-hospital stay is 1.9 d
Mean
Prostatic neoplasms
Prostatectomy
Laparoscopy
Robotics
34. Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Perioperative Outcomes
and Complications After Robot-assisted Radical Prostatectomy
• Giacomo Novara *, Vincenzo rate was ,9%, with C. Rosen , the complications being of
The mean complication Ficarra Raymond most of Walter Artibani ,
Anthony Costello , James A. Eastham , Markus Graefen , Giorgio Guazzoni ,
low grade
Shahrokh F. Shariat , Jens-Uwe Stolzenburg , Hendrik Van Poppel , Filiberto Zattoni ,
a,
a,b
e
c
f
i
d
g
j
h
k
a
Francesco Montorsi l, Alexandre Mottrie b, Timothy G. Wilson m
• Lymphocele/lymphorrea (3.1%), urine leak (1.8%), and reoperation (1.6%) are
the most prevalent surgical complications
a
University of Padua, Padua, Italy;
Watertown, MA, USA;
d
b
O.L.V. Robotic Surgery Institute, Aalst, Belgium;
Cancer Center, New York, NY, USA;
g
k
Department of Epidemiology, New England Research Institutes, Inc.,
f
Memorial Sloan-Kettering
Martini-Clinic, Prostate Cancer Centre, University Hamburg-Eppendorf, Hamburg, Germany;
h
University Vita-Salute San
Raffaele, H. San Raffaele-Turro, Milan, Italy;
i
e
c
Royal Melbourne Hospital, Grattan Street, Melbourne, Australia;
University of Verona, Verona, Italy;
Weill Medical College of Cornell University, New York, NY, USA;
University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium;
l
j
University of Leipzig, Leipzig, Germany;
University Vita-Salute San Raffaele, H. San Raffaele, Milan, Italy;
m
City of Hope
National Cancer Center, Duarte, CA, USA
• Article infoloss (weighted mean difference: 582.77; p < 0.00001) and transfusion rate
Blood
Abstract
(odds ratio [OR]: 7.55; p < 0.00001) were lower in RARP than in RRP, whereas
Context: Perioperative complications are a major surgical outcome for radical prostaArticle history:
Accepted May 22, 2012
only transfusion rate (OR:tectomy (RP). = 0.005) was lower in robot-assisted RP (RARP),LRP
2.56; Evaluate complication rates following RARP than in risk factors
Objective: p
Published online ahead of
print on June 2, 2012
for complications after RARP, and surgical techniques to improve complication rates
after RARP. We also performed a cumulative analysis of all studies comparing RARP with
retropubic RP (RRP) or laparoscopic RP (LRP) in terms of perioperative complications.
Evidence acquisition: A systematic review of the literature was performed in August
2011, searching Medline, Embase, and Web of Science databases. A free-text protocol using
the term radical prostatectomy was applied. The following limits were used: humans;
gender (male); and publications dating from January 1, 2008. A cumulative analysis was
conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK).
Evidence synthesis: We retrieved 110 papers evaluating oncologic outcomes following
RARP. Overall mean operative time is 152 min; mean blood loss is 166 ml; mean
transfusion rate is 2%; mean catheterization time is 6.3 d; and mean in-hospital stay
is 1.9 d. The mean complication rate was 9%, with most of the complications being of low
grade. Lymphocele/lymphorrea (3.1%), urine leak (1.8%), and reoperation (1.6%) are the
most prevalent surgical complications. Blood loss (weighted mean difference: 582.77;
• Keywords: can be performed routinely with a relatively small risk of complications.
RARP
Prostatic neoplasms
Prostatectomy experience, clinical patient characteristics, and cancer characteristics
Surgical
Laparoscopy
Robotics affect the risk of complications
may
35. Continence
EUROPEAN UROLOGY 62 (2012) 405–417
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Studies Reporting
Urinary Continence Recovery After Robot-assisted Radical
Prostatectomy
Vincenzo Ficarra a,b,*, Giacomo Novara a, Raymond C. Rosen c, Walter Artibani d,
Peter R. Carroll e, Anthony Costello f, Mani Menon g, Francesco Montorsi h, Vipul R. Patel i,
Jens-Uwe Stolzenburg j, Henk Van der Poel k, Timothy G. Wilson l, Filiberto Zattoni a,
Alexandre Mottrie b
a
University of Padua, Padua, Italy;
Verona, Italy;
h
e
b
O.L.V. Clinic, Aalst, Belgium;
c
New England Research Institutes, Inc., Watertown, MA, USA;
University of California, San Francisco, CA, USA; f Royal Melbourne Hospital, Melbourne, Australia;
g
d
University of Verona,
Henry Ford Hospital, Detroit, MI, USA;
Vita-Salute San Raffaele University, Milan, Italy; i Global Robotic Institute, Florida Hospital Celebration Health, Orlando, FL, USA; j University of Leipzig,
Leipzig, Germany;
Article info
k
Netherlands Cancer Institute, Amsterdam, The Netherlands; l City of Hope Cancer Center, Duarte, CA, USA
Abstract
36. Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Studies Reporting
Urinary Continence Recovery After Robot-assisted Radical
Prostatectomy
Vincenzo Ficarra a,b,*, Giacomo Novara a, Raymond C. Rosen c, Walter Artibani d,
Peter R. Carroll e, Anthony Costello f, Mani Menon g, Francesco Montorsi h, Vipul R. Patel i,
Jens-Uwe Stolzenburg j, Henk Van der Poel k, Timothy G. Wilson l, Filiberto Zattoni a,
Alexandre Mottrie b
• 51 articles reporting urinary continence rates after RARP
• The 12-mo urinary incontinence rates ranged from 4% to 31%, with a
mean value of 16% using a no pad definition.
• Posterior musculofascial reconstruction with or without anterior
reconstruction was associated with a small advantage in urinary
continence recovery 1 mo after RARP.
• Only complete reconstruction was associated with a significant
advantage in urinary continence 3 mo after RARP (odds ratio [OR]:
0.76; p=0.04)
• Cumulative analyses showed a better 12-mo urinary continence recovery
after RARP in comparison with RRP (OR: 1.53; p=0.03) or LRP (OR:
2.39; p=0.006)
a
University of Padua, Padua, Italy;
Verona, Italy;
h
e
b
O.L.V. Clinic, Aalst, Belgium;
University of California, San Francisco, CA, USA;
Vita-Salute San Raffaele University, Milan, Italy;
Leipzig, Germany;
k
i
f
c
New England Research Institutes, Inc., Watertown, MA, USA;
Royal Melbourne Hospital, Melbourne, Australia;
g
d
Global Robotic Institute, Florida Hospital Celebration Health, Orlando, FL, USA;
Netherlands Cancer Institute, Amsterdam, The Netherlands;
l
University of Veron
Henry Ford Hospital, Detroit, MI, US
j
University of Leipz
City of Hope Cancer Center, Duarte, CA, USA
Article info
Abstract
Article history:
Accepted May 22, 2012
Published online ahead of
print on May 31, 2012
Context: Robot-assisted radical prostatectomy (RARP) was proposed to improve fun
tional outcomes in comparison with retropubic radical prostatectomy (RRP) or lapar
scopic radical prostatectomy (LRP). In the initial RARP series, 12-mo urinary continen
recovery rates ranged from 84% to 97%. However, the few available studies comparing RAR
with RRP or LRP published before 2008 did not permit any definitive conclusions about th
superiority of any one of these techniques in terms of urinary continence recovery.
Objective: The aims of this systematic review were (1) to evaluate the prevalence an
risk factors for urinary incontinence after RARP, (2) to identify surgical techniqu
able to improve urinary continence recovery after RARP, and (3) to perform a cumulativ
analysis of all available studies comparing RARP versus RRP or LRP in terms of th
urinary continence recovery rate.
Evidence acquisition: A literature search was performed in August 2011 using th
Medline, Embase, and Web of Science databases. The Medline search included only
free-text protocol using the term radical prostatectomy across the title and abstract fiel
of the records. The following limits were used: humans; gender (male); and publicatio
date from January 1, 2008. Searches of the Embase and Web of Science databases use
the same free-text protocol, keywords, and search period. Only comparative studies
clinical series including >100 cases reporting urinary continence outcomes we
included in this review. Cumulative analysis was conducted using the Review Manag
v.4.2 software designed for composing Cochrane Reviews (Cochrane Collaboratio
Oxford, UK).
Evidence synthesis: We analyzed 51 articles reporting urinary continence rates aft
RARP: 17 case series, 17 studies comparing different techniques in the context of RAR
Keywords:
Prostatic neoplasms
Prostatectomy
Laparoscopy
Robotics
Please visit
www.eu-acme.org/
europeanurology to read and
answer questions on-line.
37. Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Studies Reporting
Urinary Continence Recovery After Robot-assisted Radical
Prostatectomy
*, Giacomo Novara , Raymond
Vincenzo Ficarra
Peter R. Carroll , Anthony Costello , Mani Menon , C. Rosen , Walter Artibani , R. Patel ,
Francesco Montorsi , Vipul
Jens-Uweprevalence Henk Van der Poel , Timothy G. after RARP isZattoni ,
Stolzenburg , of urinary incontinence Wilson , Filiberto influenced
• The Mottrie
Alexandre
by preoperative patient characteristics, surgeon experience,
surgical technique, and methods used to collect and report data
a,b,
a
e
c
f
d
g
j
k
h
i
l
a
b
a
University of Padua, Padua, Italy;
Verona, Italy;
h
e
b
O.L.V. Clinic, Aalst, Belgium;
University of California, San Francisco, CA, USA;
Vita-Salute San Raffaele University, Milan, Italy;
Leipzig, Germany;
k
i
f
c
New England Research Institutes, Inc., Watertown, MA, USA;
Royal Melbourne Hospital, Melbourne, Australia;
d
l
University of Veron
Henry Ford Hospital, Detroit, MI, US
Global Robotic Institute, Florida Hospital Celebration Health, Orlando, FL, USA;
Netherlands Cancer Institute, Amsterdam, The Netherlands;
Article info
g
j
University of Leipz
City of Hope Cancer Center, Duarte, CA, USA
Abstract
• Posterior musculofascial reconstruction seems to offer a slight
advantage in terms of 1-mo urinary continence recovery
Article history:
Accepted May 22, 2012
Published online ahead of
print on May 31, 2012
Keywords:
Prostatic neoplasms
Prostatectomy
Laparoscopy
Robotics
Context: Robot-assisted radical prostatectomy (RARP) was proposed to improve fun
tional outcomes in comparison with retropubic radical prostatectomy (RRP) or lapar
scopic radical prostatectomy (LRP). In the initial RARP series, 12-mo urinary continen
recovery rates ranged from 84% to 97%. However, the few available studies comparing RAR
with RRP or LRP published before 2008 did not permit any definitive conclusions about th
superiority of any one of these techniques in terms of urinary continence recovery.
Objective: The aims of this systematic review were (1) to evaluate the prevalence an
risk factors for urinary incontinence after RARP, (2) to identify surgical techniqu
able to improve urinary continence recovery after RARP, and (3) to perform a cumulativ
analysis of all available studies comparing RARP versus RRP or LRP in terms of th
urinary continence recovery rate.
Evidence acquisition: A literature search was performed in August 2011 using th
Medline, Embase, and Web of Science databases. The Medline search included only
free-text protocol using the term radical prostatectomy across the title and abstract fiel
of the records. The following limits were used: humans; gender (male); and publicatio
date from January 1, 2008. Searches of the Embase and Web of Science databases use
the same free-text protocol, keywords, and search period. Only comparative studies
clinical series including >100 cases reporting urinary continence outcomes we
included in this review. Cumulative analysis was conducted using the Review Manag
v.4.2 software designed for composing Cochrane Reviews (Cochrane Collaboratio
Oxford, UK).
Evidence synthesis: We analyzed 51 articles reporting urinary continence rates aft
RARP: 17 case series, 17 studies comparing different techniques in the context of RAR
• Update of a previous systematic review of literature shows, for the
first time, a statistically significant advantage in favor of RARP in
comparison with both RRP and LRP in terms of 12-mo urinary
continence recovery
Please visit
www.eu-acme.org/
europeanurology to read and
answer questions on-line.
42. What makes robotic surgery expensive ?
! The initial cost is extremely high, estimated to be about $1.8
million and the maintenance costs
! After ten uses of a robot, the instruments must be replaced
! Use of the robot comes with a slower learning curve for doctors.
! When hospitals attempt to balance patient safety with the high
training costs, sometimes poor patient outcomes occur.
! There are also increased costs to the patient per surgery, estimated
at around $2,500 per procedure compared to traditional methods
43. Robotic prostatectomy will always be more costly to the NHS because of the fixed
capital and maintenance charges for the robotic system
Our modelling showed that this excess cost can be reduced if capital costs of equipment
are minimised and by maintaining a high case volume for each robotic system of at least
100–150 procedures per year. This finding was primarily driven by a difference in
positive margin rate
44. How can we improve robotic
surgical outcomes
! Regulation of Training
45. How can we improve robotic
surgical outcomes
! Simulation
! Simulation and Technology enhanced Learning Initiative
(STeLI) project
! SAGES / RAST (Robotic assisted surgical training) programme
! Formal Fellowship training
! 6 robotic fellowships in the UK
! Only one recognized by the RCS/BAUS
! Strict audit of outcomes
50. Conclusion
! Men undergoing a Robotic Prostatectomy appear to have :Lower intraoperative blood loss
Reduced surgical morbidity
Lower risk of a positive margin
Reduced risk of cancer recurrence and hence need to further
treatment
! Oncological outcomes are equivalent
! No evidence that men undergoing a RRP are disadvantaged in
terms of functional outcomes
! Longer follow up is required to relative effectiveness
!
!
!
!
51. Conclusion
“The Surgeon is the most important determinant of robotic
radical prostatectomy outcomes of peri-operative
complications, length of stay and strictures”
L Klotz
“The aim now should be to evaluate the cost of robotic
prostatectomy results in long term gain for patient”
J Meeks
52. Correspondence
! Mr Nikhil Vasdev
Post CCT Robotic Urological Fellow
(RCSEng/BAUS National Accredited Fellowship Programme)
Hertfordshire and South Bedfordshire Urological Cancer Centre
Lister Hospital
Stevenage
UK
Email –
nikhilvasdev@doctors.org.uk
Website – www.roboticsinsurgery.org