You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VII1 Apr 2016MP80-06 INTRAOPERATIVE BIMANUAL EXAMINATION AND FROZEN-SECTION ANALYSIS DURING ROBOT-ASSISTED RADICAL PROSTATECTOMY: A NOVEL TECHNIQUE FOR REDUCING POSITIVE SURGICAL MARGINS Akshay Sood, Deepansh Dalela, Wooju Jeong, Khurshid Ghani, Mireya Diaz-Insua, Stacey Dusik, Nilesh Gupta, Mani Menon, and James Peabody Akshay SoodAkshay Sood More articles by this author , Deepansh DalelaDeepansh Dalela More articles by this author , Wooju JeongWooju Jeong More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , Mireya Diaz-InsuaMireya Diaz-Insua More articles by this author , Stacey DusikStacey Dusik More articles by this author , Nilesh GuptaNilesh Gupta More articles by this author , Mani MenonMani Menon More articles by this author , and James PeabodyJames Peabody More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2038AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To describe the feasibility and early outcomes of a Modification to robot-assisted radical prostatectomy (RARP) that allows for mitigation of the lack of tactile feedback during RARP by allowing immediate Organ Retrieval for Examination and targeted frozen-section biopsies (MORE technique). METHODS MORE consists of a GelPOINT device inserted periumbilically. Prostate is excised and retrieved through the GelPOINT without undocking the robot, and examined bimanually on-table by the surgeon. Lesions suspicious for positive surgical margin (PSM) are sent for frozen section analysis (Figure). Biopsies positive/suspicious for cancer resulted in more tissue excision from the corresponding pelvic bed site. 352 patients with a probability of extracapsular extension (EPE) >25% (Partin table) were selected to undergo MORE RARP. MORE RARP patients with pT3a at final pathology (n=103) were compared to a control group of 74 consecutive patients with pT3a after conventional RARP. RESULTS Except a greater proportion of clinically palpable disease in the MORE RARP vs. control group (43.7 vs. 17.6%; p=0.005), the two groups had comparable rates of nodal dissection, nerve sparing, pathological stage, grade and nodal status. The PSM rate in the MORE group was 17.5% (18/103) compared to 36.5% (27/74) in the control group (p=0.004); the odds ratio was 0.37 (CI: 0.18-0.74; p=0.005). 8 patients in each group had biochemical recurrence; short follow-up (median 16.6 and 15.4 months respectively) precluded detection of any significant difference. Frozen section biopsy site matched the EPE site at final pathology in 59/79 (73.4%) cases selected for frozen section analyses. CONCLUSIONS Adoption of the MORE technique led to a significant reduction in the PSM rate following RARP in patients harboring locally advanced disease without increasing operative time. Its easy reproducibility may also allow potential utility in other robot-assisted urologic oncologic procedures. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1045 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Akshay Sood More articles by this author Deepansh Dalela More articles by this author Wooju Jeong More articles by this author Khurshid Ghani More articles by this author Mireya Diaz-Insua More articles by this author Stacey Dusik More articles by this author Nilesh Gupta More articles by this author Mani Menon More articles by this author James Peabody More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTechnology & Instruments: Robotics: Benign & Malignant Disease (I)1 Apr 2013845 BIMANUAL EXAMINATION OF RETRIEVED SPECIMEN DURING ROBOT-ASSISTED RADICAL PROSTATECTOMY: A NOVEL TECHNIQUE FOR REDUCING THE POSTIVE SURGICAL MARGIN Wooju Jeong, Khurshid R. Ghani, Akshay Sood, Stacey Dusik, Craig G. Rogers, Nilesh S. Gupta, Prokar Dasgupta, James O. Peabody, and Mani Menon Wooju JeongWooju Jeong Detroit, MI More articles by this author , Khurshid R. GhaniKhurshid R. Ghani Detroit, MI More articles by this author , Akshay SoodAkshay Sood Detroit, MI More articles by this author , Stacey DusikStacey Dusik Detroit, MI More articles by this author , Craig G. RogersCraig G. Rogers Detroit, MI More articles by this author , Nilesh S. GuptaNilesh S. Gupta Detroit, MI More articles by this author , Prokar DasguptaProkar Dasgupta London, United Kingdom More articles by this author , James O. PeabodyJames O. Peabody Detroit, MI More articles by this author , and Mani MenonMani Menon Detroit, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.413AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A putative drawback of robot-assisted radical prostatectomy (RARP) is the lack of tactile sensation and the ability to determine possible tumor margins. We describe a modified technique of RARP that allows immediate organ retrieval for intraoperative examination and targeted frozen section biopsies (MORE procedure). The aim of this study was to determine feasibility and early outcomes. METHODS 117 patients with a probability of extracapsular extension (EPE) >25% by Partinõs tables were selected to undergo MORE-RARP. MORE consists of a GelPOINT” access port (Applied Medical, CA, USA) placed in the periumbilical region with a 12mm camera port and 10mm port for retrieval. Following excision of the prostate, it is retrieved through the GelPOINT, and examined on-table by the surgeon. Lesions suspicious for positive margins are sent for frozen section biopsy. Biopsies positive or suspicious for cancer resulted in more tissue being removed. Patients undergoing MORE with pT3a at final pathology were compared to a control group of patients with pT3a after conventional RARP. RESULTS In the MORE group, 30 out of 117 patients were diagnosed with pT3a disease. There were no significant differences in baseline characteristics between control patients and patients undergoing MORE procedure. 8/30 patients in the MORE group and 5/30 patients in the control group had GS |8 at biopsy. Total operating times between MORE vs control groups were not significantly different (182.5 vs 175.9 minutes respectively, p=0.69). The PSM rate in the control group was 43.3% (13/30) compared to 16.7% (5/30) in MORE (p=0.047), and the relative risk ratio was 2.6 (CI: 1.06 - 6.33; p=0.037) (Table 1). In 70.8% of MORE, the site selected for frozen section biopsy matched the EPE site at final pathology. CONCLUSIONS Using GelPoint allowed to examine the retrieved prostate bimanually. In this pilot study, adoption of the MORE procedure at RARP led to a significant reduction in the PSM rate in pT3a prostate cancer. MORE is a promising technique that has potential in other minimally invasive urologic oncologic procedures. Patients characteristics GelPoint (N=30) Control (N=30) p Age (year-old) 61.4 ± 6.8 61.4 ± 6.9 0.999 BMI (kg/m2) 29.1 ± 3.5 27.2 ± 4.2 0.053 PSA (ng/dL) 9.5 ± 10.2 7.4 ± 3.5 0.288 Biospy GS (%) 0.241 GS 3+3 3 (10.0) 0 (0.0) GS 3+4 10 (33.3) 14 (46.7) GS 4+3 9 (30.0) 11 (36.7) GS 4+4 or higher 8 (26.7) 5 (16.7) Clinical stage (%) 0.023 T1 13 (43.3) 21 (70.0) T2a-b 12 (50.0) 5 (16.7) T2c or higher 2 (6.7) 4 (13.3) IPSS 8.6 ± 5.4 5.3 ± 4.4 0.017 SHIM 18.1 ± 7.5 19.5 ± 6.1 0.445 Operative times (min.) OR time 182.5 ± 52.3 175.9 ± 73.3 0.690 Console time 132.6 ± 43.9 134.2 ± 66.9 0.915 Estimated Blood Loss (mL) 96.0 ± 56.8 120.1 ± 90.7 0.209 Prostate Wt (gm) 46.3 ± 15.2 44.8 ± 14.3 0.683 Tumor Vol (%) 19.7 ± 13.1 17.8 ± 11.9 0.558 Pathological GS (%) 0.102 GS 3+3 0 (0.0) 0 (0.0) GS 3+4 9 (30.0) 16 (53.3) GS 4+3 11 (36.7) 10 (33.3) GS 4+4 or higher 10 (33.3) 4 (13.3) Surgical margin 0.047 negative 25 (83.3) 17 (56.7) positive 5 (16.7) 13 (43.3) © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e347 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wooju Jeong Detroit, MI More articles by this author Khurshid R. Ghani Detroit, MI More articles by this author Akshay Sood Detroit, MI More articles by this author Stacey Dusik Detroit, MI More articles by this author Craig G. Rogers Detroit, MI More articles by this author Nilesh S. Gupta Detroit, MI More articles by this author Prokar Dasgupta London, United Kingdom More articles by this author James O. Peabody Detroit, MI More articles by this author Mani Menon Detroit, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyRobotics, Single Port Surgery, LESS, NOTES1 Apr 2013V2156 BIMANUAL EXAMINATION OF RETRIEVED SPECIMEN AND REGIONAL HYPOTHERMIA DURING ROBOT-ASSISTED RADICAL PROSTATECTOMY Wooju Jeong, Khurshid R. Ghani, Akshay Sood, Stacey Dusik, Ramesh Kumar, Craig G. Rogers, Nilesh S. Gupta, Prokar Dasgupta, James O. Peabody, and Mani Menon Wooju JeongWooju Jeong Detroit, MI , Khurshid R. GhaniKhurshid R. Ghani Detroit, MI , Akshay SoodAkshay Sood Detroit, MI , Stacey DusikStacey Dusik Detroit, MI , Ramesh KumarRamesh Kumar Detroit, MI , Craig G. RogersCraig G. Rogers Detroit, MI , Nilesh S. GuptaNilesh S. Gupta Detroit, MI , Prokar DasguptaProkar Dasgupta London, United Kingdom , James O. PeabodyJames O. Peabody Detroit, MI , and Mani MenonMani Menon Detroit, MI View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2065AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We Modified our robotic prostatectomy procedure using the GelPOINT̈ access port to allow immediate Organ Retrieval for on-table Examination and targeted frozen section biopsies, or the MORE procedure, and to induce regional hypothermia by putting ice slush into the pelvic cavity. The goal of these new techniques is to determine if bimanual palpation of the specimen can help reduce the positive surgical margin (PSM) rate in pT3a disease through immediate evaluation of the prostate specimen and to evaluate the feasibility of achieving regional hypothermia during the RARP. METHODS 117 patients were selected to undergo MORE-RARP procedure. Regional hypothermia procedures were performed in 32 out 117 MORE-RARP patients. MORE consists of a GelPOINT̈ access port placed in the periumbilical region with a 12mm camera port and 10mm port, which enables the assistant to retrieve the specimen and introduce iced saline slush into the pelvic cavity. The configuration of other ports is same as for conventional robotic prostatectomy. Following excision of the prostate, it is retrieved through GelPOINT and examined on-table by the surgeon, and can be sent for frozen section analysis while the console surgeon performs lymph node dissection. Lesions suspicious for positive margins are sent for frozen section biopsy. If biopsies are positive or suspicious for cancer, more tissue is removed from the area overlying the positive margin (n=10). Iced saline is introduced using a rigid sigmoidoscope through GelPOINT during the procedure. A 9F esophageal temperature probe was used to measure the temperature of the pelvic cavity. The other steps of the robotic prostatectomy are same as for a conventional procedure. RESULTS In the MORE group, 30/117 patients were diagnosed with pT3a disease. There were no significant differences in baseline characteristics between control patients and patients undergoing MORE procedure. Total operating times between MORE and control groups were not significantly different. The pT3a PSM rate in the control group was 43.3% compared to 16.7% in MORE. 2/10 specimen had adenocarcinoma from the additional tissue. Using iced saline during RARP, this technique achieved temperature of 15° C in the pelvic cavity with no obvious body temperature change. CONCLUSIONS In this pilot study, adoption of the MORE procedure at RARP led to a significant reduction in the PSM rate in pT3a prostate cancer. We have demonstrated the feasibility of a novel technique of regional hypothermia using iced saline during RARP and this technique was reproducible. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e883 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wooju Jeong Detroit, MI More articles by this author Khurshid R. Ghani Detroit, MI More articles by this author Akshay Sood Detroit, MI More articles by this author Stacey Dusik Detroit, MI More articles by this author Ramesh Kumar Detroit, MI More articles by this author Craig G. Rogers Detroit, MI More articles by this author Nilesh S. Gupta Detroit, MI More articles by this author Prokar Dasgupta London, United Kingdom More articles by this author James O. Peabody Detroit, MI More articles by this author Mani Menon Detroit, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OBJECTIVE:To describe our technique of maintaining bladder drainage after robot-assisted radical prostatectomy (RARP) using a percutaneous suprapubic tube (PST) in place of a urethral catheter.METHODS:A watertight anastomosis permits placement of the PST. Contraindications include morbid obesity, concomitant inguinal hernia mesh repair, anticoagulation therapy, limited hand dexterity in the patient, bladder neck reconstruction and extensive adhesiolysis at RARP. The necessary equipment includes a 14-F PST balloon catheter set, a three-way connector, a connecting tube, a suture passer, 1/0 polypropylene sutures on a CT1 needle, a sterile plastic button, adhesive and steri-strips.RESULTS:The important steps for PST placement are: Step 1: robot-assisted placement of a bladder wall anchor suture; Step 2: transferring the bladder wall suture to anterior abdominal skin; Step 3: guided placement of the PST under robotic vision; Step 4: securing the PST within the bladder and abdominal wall; Step 5. postoperative care: clamping the PST on postoperative day 5, recording each void and post-void residual urine volumes in a patient diary, removal of the PST on postoperative day 7 after 48 h of voiding with residual urine <100 mL per void.CONCLUSION:We provide a concise step-by-step guide for placement of a PST during RARP as well as important management aspects for the successful adoption of this technique.

In this video, the role of the assistant is addressed during robotic partial nephrectomy. The steps choreographed in this video are universally applicable to all assistants, and are not limited to specialized centers. During the advent of this procedure, several surgeons voiced concerns of the ability of an inexperienced assistant to perform some critical maneuvers such as clamping, clipping, and suction. Our experience mirrors that of the authors, in which the relative experience of the assistant is not a factor in outcomes of robot-assisted partial nephrectomy. All assistants should watch this short video as a primer on their role during the operation. Sam B. Bhayani, M.D. Associate Professor, Urology Washington University School of Medicine, St. Louis, Missouri. Introduction: The bedside assistant is important in achieving success in robotic partial nephrectomy (RPN). In this video, we present the major steps of RPN, with an emphasis on the role of the bedside assistant. We also compare our outcomes with RPN stratified by the experience level of the assistant. Methods: Major steps of RPN in which the bedside assistant has an important role include port placement, bowel mobilization, spleen or liver retraction, ureter and gonadal vein dissection, hilar dissection, tumor localization, hilar clamping, tumor resection, renorrhaphy, unclamping, and removal of the specimen. Perioperative outcomes for 78 consecutive RPN cases performed by a single surgeon were compared between experienced assistants (those who assisted on >100 robotic prostatectomy cases with laparoscopic kidney experience) and inexperienced assistants. Results and Conclusions: We identified on video at least 12 steps during RPN in which maneuvers performed by a trained assistant could be beneficial. Although perioperative outcomes between cases performed by experienced assistants (n = 28) and inexperienced assistants (n = 50) were similar, experienced assistants were more likely to assist on more complex RPN cases (endophytic involving collecting system repair; 58% vs. 33%, p = 0.04). In conclusion, the bedside assistant plays an important role in RPN. We present key steps in the procedure in which the assistant can have a role in facilitating excellent outcomes in RPN. No competing financial interests exist. Runtime of video: 6 mins 32 secs