Urological Surgery


statistically significant difference in the reported costs could be shown. The average cost for the robotic group was US$3,467 compared with US$2,737 for the standard laparoscopic group.


reported a complication rate of 7% (two of 30 patients; one case of prolonged ileus and one brief episode of hypoxia), median hospitalisation was two days and, very interestingly, no significant differences in costs between robotic and laparoscopic adrenalectomy could be observed.


Winter et al.74 In 2006, St Julien et al.78 published data on the first robotic partial


adrenalectomy. This procedure was performed on an 18-year-old male patient with von Hippel-Lindau disease. Prior to the partial adrenalectomy the patient had open left adrenalectomy for pheochromocytoma. The robotic partial adrenalectomy was performed because of recurrence of pheochromocytoma in his right adrenal gland. Most recently, Kumar et al.79


published their results of


the first robot-assisted partial adrenalectomy performed on an isolated adrenal metastasis. The patient operated on experienced a 7mm adrenal recurrence of a renal clear cell carcinoma. The authors reported no peri-operative complications and the patient could be discharged on post-operative day three.


The enhanced visualisation and precise manipulation of small lesions are the most important advantages of current robotic surgery. They allow a meticulous removal of small adrenal masses without the need for total adrenalectomy.


Current literature has demonstrated the feasibility of robotic adrenalectomy, whether for a partial or total resection of the gland. Functional outcome data are similar to data from laparoscopic series. However, as already mentioned for other procedures, the cost factor is a drawback of robotic surgery. It is clear that more prospective randomised studies are needed to draw decisive conclusions about whether robotic adrenalectomy is really superior or at least equivalent to the conventional laparoscopic approach. Current literature still favours laparoscopic surgery in terms of feasibility, length of procedure and direct and indirect costs.76


Robot-assisted Radical Prostatectomy Since its first appearance, robot-assisted radical prostatectomy (RALP) has gained widespread attention and has led to a substantial change in the treatment of prostate cancer. RALP is displacing retropubic radical prostatectomy as the gold standard surgical approach for clinically localised prostate cancer. Currently, an estimated 80% of prostatectomies in the US are performed using robotic assistance.80


The saturation of the European market with Intuitive Surgical’s da Vinci robotic system is still not that advanced.


The first RALP procedure was performed in May 2000 by Binder et al.81 In the following years Menon et al. developed the most commonly used technique for RALP, the Vattikuti Institute prostatectomy (VIP).82 Ahlering et al.83


antegrade, transperitoneal approach.


Another ground-breaking publication for robotic prostatic surgery was the modification of the VIP technique by Kaul et al.84


The authors


described the preservation of the prostatic fascia (‘veil of Aphrodite’), and concluded that if this procedure is performed correctly, neural tissue is better preserved and therefore improvements in


74


potency rates can be observed. This conclusion rose due to S-100 nerve-staining methods to stain and count the nerve bundles remaining within the anterolateral periprostatic fascia in patients who underwent standard versus modified VIP RALP. Histological investigations showed that the standard group had a mean of 10 nerve bundles compared with only two in the modified VIP group (pin situ. Therefore, a better recovery of post-operative erectile function should be possible. Initial reports by Menon et al.85


using the modified


VIP technique showed a potency rate of 94% in a selected group of 85 men. However, these figures have not been replicated in current literature. Novara et al.86


recently published a more realistic result


of a 62% potency rate 12 months post-operatively. Regarding better urinary continence, Rocco et al.87


demonstrated the


need for posterior reconstruction of the Denonvillier’s fascia and the posterior rhabdosphincter. The authors concluded that the better posterior support to the reconstructed urethral sphincteric complex and its greater anatomical and functional length should be responsible for the improved post-operative continence rate observed. Using the zero to one pad definition of urinary continence, Rocco et al.87


noted continence rates of 72 versus 14%, 79 versus 30% and 86 versus 46% at three days, one month and three months in the study and control groups, respectively. Furthermore, Tewari et al.88 showed the superiority of a total (anterior and posterior) reconstruction of the vesicourethral junction over either a posterior only or no reconstruction. By total reconstruction the authors referred to the re-suspension of the anastomosis and distal bladder neck to the arcus tendineus in addition to the Rocco stitch. The objective evaluation of post-operative functional outcome regarding urinary continence and potency is hindered by the lack of standardisation of outcome reporting. Validated tools exist but their use is not very popular. Current data indicates that a continence rate between 88 and 97%89,90


can be observed 12 months post-operatively


when using the criteria of no pads or one security pad. Urological doctrine has teached us that the urethral anastomosis should always be bridged with a urethral catheter after radical prostatectomy in order to prevent mucosal cross-healing and stricture formation. However, urethral catheterisation is often associated with physical limitations. Lepor et al. reported that 54% of patients report moderate or severe physical limitations when the urethral catheter is placed.91 In 2009, interesting data were published by Menon et al. The authors reported on their experience with percutaneous suprapubic tube (PST) drainage instead of the conventional urethral catheterisation after robotic radical prostatectomy.92


The idea behind this study was


to evaluate patient discomfort, complications, continence and stricture rate after percutaneous suprapubic tube bladder drainage.


published the most important modifications in the


Two hundred and two patients received a 14F PST intra-operatively. On day one after the operation the urethral catheter was discharged, leaving the PST as drainage. Beginning on post-operative day five, patients started to clamp the PST in order to urinate per urethra. The PST was removed as soon as the post-void residual urine drained by the PST was


EUROPEAN UROLOGICAL REVIEW


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