ROBOTICS AND UROLOGY. 4/5 ABSTRACTS MEETING OF THE AMERICAN UROLOGICAL ASSOCIATION.

Sunday, May 18, 2014 1:00 PM-3:00 PM
OCCC:
Outstanding Posters: Benign Disease
Funding: None
OP2-04: Diffusion of Minimally Invasive Radical Prostatectomy: The Public Consequence of an Untested Treatment 
Christopher Anderson*, Coral Atoria, Elena Elkin, James Eastham, Karim Touijer, New York, NY

Abstract: OP2-04
Introduction and Objectives
The dissemination of minimally invasive radical prostatectomy (MIRP) has occurred with limited evidence of its superiority to open radical prostatectomy (ORP). While specialty centers report similar results between ORP and MIRP, the widespread diffusion of MIRP may have led to adverse patient outcomes. We hypothesized that MIRP was associated with inferior outcomes early in the adoption of robotic technology.Methods
In the population-based SEER-Medicare dataset, we identified men age ≥66 who had ORP or MIRP for prostate cancer from 2003-2008. Study endpoints were receipt of secondary cancer treatment (radiation or hormonal therapy) at any time after surgery, and evidence of incontinence, erectile dysfunction (ED) and bladder outlet obstruction (BOO) at ≥3 months postoperatively, based on Medicare claims. We used proportional hazards regression to estimate the impact of surgical approach on each endpoint. Our model included a propensity score for the likelihood of MIRP and an interaction term to test for modification of the effect of surgical approach by year of surgery.

Results
MIRP (n=6,207) and ORP (n=2,932) patients differed significantly in their clinical and demographic characteristics. Median follow-up was 3 years for MIRP and 4.6 years for ORP. MIRP patients were treated by higher volume surgeons (median annual volume 10 vs. 5). MIRP patients had fewer secondary cancer treatments (15% vs. 23%), although this difference was not significant (HR 0.89 [95% CI 0.76-1.05]) controlling for patient characteristics and surgeon volume. There was no interaction between surgical approach and year (figure A). MIRP patients were more likely to have claims reflecting incontinence (54% vs. 47%) and ED (60% vs. 47%), but less likely to have BOO (19% vs. 29%). Controlling for patient characteristics and surgeon volume, MIRP was associated with a higher risk of incontinence (HR 1.3 [95% CI 1.2-1.43]) and ED (HR 1.43 [95% CI 1.31-1.56]), but a lower risk of BOO (HR 0.86 [95% CI 0.75, 0.97]) with no effect modification by year for any endpoint (figures B-D).

Conclusions
MIRP patients had adverse urinary and sexual outcomes throughout the early diffusion of robotic technology. With the growing influx of advanced surgical technologies, systems to guide safe adoption practices will gain importance.

Date & Time: May 18, 2014 1:00 PM-3:00 PM
Session Title: Outstanding Posters: Benign Disease
Sources of Funding: None

 

Sunday, May 18, 2014 1:00 PM-3:00 PM
OCCC:
Outstanding Posters: Benign Disease
Funding: none
OP2-10: Performance of Robotic Simulated Skills Tasks is Positively Associated with Clinical Robotic Surgical Performance 
Monty Aghazadeh*, Michael Pan, Miguel Mercado, Brian Dunkin, Alvin Goh, Houston, TX

Abstract: OP2-10
Introduction and Objectives
To date, there is no data in the robotic environment showing a significant relationship between simulation and clinical performance. Our group has previously demonstrated face, content, and construct validity of 4 Fundamental Inanimate Robotic Skills Tasks (FIRST) as well as 8 daVinci Skills Simulator (dVSS) virtual reality tasks. Herein, we compare user performance of these simulated robotic skills tasks (inanimate and virtual reality) to intraoperative performance (concurrent validity) during robotic prostatectomy (RP)Methods
Seventeen urologic surgeons of varying robotic experience, including urology residents, fellows, and attendings, were enrolled in the study. Demographic and prior robotic experience were captured using a standardized questionnaire. User performance was assessed concurrently in simulated (FIRST exercises and dVSS tasks) and clinical environments (endopelvic dissection during RP). Intraoperative robotic clinical performance of participants was scored by the attending surgeon using the previously validated 6-metric Global Evaluative Assesment of Robotic Skills (GEARS) tool (expert performance was scored by a separate attending observer). Simulator and clinical performance were correlated using Spearman’s analysis.

Results
Performance was assessed in 13 trainees (PGY 2-6) and 4 expert robotic surgeons with >30 cases (1 fellow, 3 attendings). Median age (range) of the trainee and expert group was 29 (26-33) and 36.5 years old (33-48), respectively (p=0.001). Median number of robotic cases (range) performed as primary surgeon for the trainee group was 16 (0-27) and 117 (58-600) for the expert group (p=0.001). Collectively, the overall FIRST (ρ = 0.829, p <0.001) and dVSS (ρ = 0.742, p=0.001) simulation scores highly correlated with total GEARS performance scores. Further analysis of the individual FIRST and dVSS tasks demonstrated statistically significant correlation of task score to intraoperative performance with the exception of Energy Switcher 1 (p=0.078) (Table 1).

Conclusions
This is the first study to demonstrate a significant correlation between baseline simulated robotic performance and robotic clinical performance (concurrent validity). Of note, the strongest correlation was observed between inanimate task scores and clinical performance, highlighting the current potential limitations of virtual simulation. These findings support the implementation of these specific inanimate and virtual reality robotic training tools in a standardized robotic training curriculum.

Date & Time: May 18, 2014 1:00 PM-3:00 PM
Session Title: Outstanding Posters: Benign Disease
Sources of Funding: none

Table 1: Correlation of Simulation Performance to GEARS Clinical Performance Scores
rho value p value
FIRST:
Total FIRST Score 0.829 <0.001
1) Horizontal Mattress Suture 0.852 <0.001
2) Clover Pattern Cut 0.780 <0.001
3) 3-D Dome and Peg 0.699 0.002
4) Circular Needle Target 0.842 <0.001
dVSS Tasks:
Total dVSS Score 0.742 0.001
1) Peg Board 1 0.783 <0.001
2) Peg Board 2 0.630 0.007
3) Ring and Rail 2 0.682 0.002
4) Ring Walk 3 0.654 0.004
5) Match Board 3 0.621 0.008
6) Suture Sponge 3 0.712 0.001
7) Tubes 0.685 0.002
8) Energy Switcher 1 0.442 0.076

 

Sunday, May 18, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
Technology & Instruments: Robotics – Benign & Malignant Disease
Funding: National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1 TR000153.
MP37-01: Hypothermic Pelvic Cooling Measured by Real Time MRI Imaging prior to Robot assisted Radical Prostatectomy (RARP); Feasibility and Implications. 
Douglas Skarecky, Hon Yu, Blanca Morales, Min-Ying (Lydia) Su, Thomas Ahlering*, Orange, CA

Abstract: MP37-01
Introduction and Objectives
This study is an innovative application of Thermal MRI imaging as a feasibility method for maximization of improved clinical outcomes of Hypothermic Endorectal Balloon (ECB) in radical prostatectomy (RP). The effective depth and spread of hypothermic cooling was quantitatively mapped by thermo MRI to assess the dispersion and drop in temperature in pelvic tissue and to potentially reduce inflammatory cascade in potency neurovascular bundles (NVB) in men.Methods
Three subjects, prior to undergoing RARP, were cooled via an ECB, rendered MRI compatible by removing metal components for patient safety (HS2012-8392). Prior to cooling hypothermia, anatomic MR images identified the pelvic structures, and measured simultaneously at 3T scanner using 29, 3-mm thick axial slices matched to that of anatomical T2w but with 46-cm FOV and in 256×256 image matrix; the sequence is based on Philips’ multishot EPI (echo planar imaging) with TR/TE=48/16 (ms), flip-angle at 20-degree and NSA=2 (‘number of average’); the sequence was performed repeatedly during the cooling experiment with 76-sec temporal resolution while the phase data were collected using an integrated MR-HIFU workstation (Sonalleve, Philips) for processing temperature changes in real time. After the anatomical scans, pelvic cooling was instituted with an RPX cooling console (Phillips Healtcare) located outside the MRI coil with 30′ of cooling tubing to reach the subject, and the thermometry scan was repeated every 6 s for one hour.

Results
Figure 1 ABC demonstrates that pelvic cooling measured in real time is feasible. A temperature drop of 20-25 degrees was achieved after an initial time delay of 10-15′ for the ECB to cool. Figure 1 middle and bottom compare the anatomic image of the prostate and NVB and demonstrate cooling at this interface of 10-15 degrees, and that cooling extends into the prostate itself ~ 5 degrees, and disperses into the pelvic region as well.

Conclusions
Using a cooling balloon modified for MRI compatibility, we have demonstrated an effective method to measure the impact of a novel ECB balloon on NVB and surrounding structures and potentially useful to visualize the effectiveness of hypothermic saturation in other urologic tissue regions as well.

Date & Time: May 18, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Robotics – Benign & Malignant Disease
Sources of Funding: National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1 TR000153.

 

Sunday, May 18, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
Technology & Instruments: Robotics – Benign & Malignant Disease
Funding: None
MP37-02: IMPACT OF SURGICAL VOLUME ON SURGICAL MARGIN STATUS IN PATIENTS TREATED WITH ROBOT-ASSISTED RADICAL PROSTATECTOMY 
Giorgio Gandaglia, Firas Abdollah, Marco Bianchi*, Roberto Bertini, Niccolò Maria Passoni, Ettore Di Trapani, Massimo Freschi, Roberta Lucianò, Milan, Italy, Vincenzo Mirone, Napoli, Italy, Pierre I Karakiewicz, Maxine Sun, Montreal, Canada, Shahrokh F Shariat, Vienna, Austria, Francesco Montorsi, Alberto Briganti, Milan, Italy

Abstract: MP37-02
Introduction and Objectives
Previous studies showed a role of surgical experience on the surgical margin status in patients treated with open radical prostatectomy (ORP), where individuals treated by less experienced surgeons were at higher risk of having positive surgical margins (PSM) at final pathology. However, evidence is scarce regarding the role of surgeon experience on the surgical margin status in prostate cancer (PCa) patients receiving robot-assisted radical prostatectomy (RARP).Methods
Overall, 1,156 patients with PCa treated with RARP between February 2006 and August 2013 by four most experienced surgeons at a single tertiary referral center were identified. All patients had available preoperative and pathological data. Surgical volume was coded as the number of robotic cases done by the surgeon before the index patient’s operation. Two multivariable logistic regression models were fitted to assess the impact of surgical volume on the risk of positive surgical margins. The first model included preoperative covariates, namely clinical stage, biopsy Gleason score, and PSA at surgery. The second model included pathological data, such as pathological stage, pathological Gleason score, and nerve-sparing status

Results
Mean patient age was 62.5 years (median: 63). Mean surgical volume was 194 (median: 190). Overall, 178 patients (15.4%) had PSM at final pathology. When patients were categorized according to pathological stage, the rate of PSM was 9.0, 38.3, and 45.2% in patients with pT2, pT3a, and pT3b/pT4 disease, respectively (P<0.001). At multivariable analyses including preoperative patient characteristics, surgical volume continuously coded was significantly associated with a reduction in the risk of PSM, after adjusting for confounders (p=0.04). Additionally, preoperative PSA and clinical stage represented independent predictors of PSM (all P≤0.01). In multivariable analyses including pathological characteristics, surgical volume remained highly associated with decreased risk of PSM, after adjusting for confounders (P=0.01). Additionally, pathological stage and pathological Gleason score, but not nerve-sparing status, represented independent predictors of PSM (all P≤0.05).

Conclusions
In patients treated with RARP, surgeon experience is an independent predictor of the surgical margin status. Particularly, patients treated by more experienced surgeons are at lower risk of PSM at final pathology. These findings highlight the role of the learning curve phenomenon typical of early adopters in the context of robotic surgery.

Date & Time: May 18, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Robotics – Benign & Malignant Disease
Sources of Funding: None

Sunday, May 18, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
Technology & Instruments: Robotics – Benign & Malignant Disease
Funding: none
MP37-04: Cerebral Oxygenation in 45 Degree Trendelenburg Position for Robot Assisted Radical Prostatectomy. A Single Center, Open, Controlled Pilote Study 
Clemens Georg Wiesinger*, Mathias Stockhammer, Lukas Mitterschiffthaler, Emir Mirtezani, Wels, Austria, Helga Wagner, Linz, Austria, Johann Knotzer, Walter Pauer, Wels, Austria

Abstract: MP37-04
Introduction and Objectives
Robot-assisted laparoscopic prostatectomy became a standard procedure in minimal invasive therapy in carcinoma of the prostate. For this procedure a 45 degree Trendelenburg position is necessary for the whole length of the operation. Changes in cerebral oxygenation and hemodynamics and possible damage to cerebral function therefore are suspected. The objectives of the study were to show changes in cerebral oxygenation and hemodynamics.Methods
55 consecutive patients, who underwent robot assisted radical prostatectomy, were included into the study. 30 consecutive patients who underwent robot assisted partial nephrectomy served as a control group. In radical prostatectomy patients we used the 45 degree Trendelenburg position, partial nephrectomy patients were placed in a flank position with the table moderately flexed. Data concerning patient position, cerebral oxygenation (regional oxygen saturation monitor), cerebral hemodynamics (RR, arterial blood gas analysis, pulse monitoring) were collected, as well as pre- and postoperative evaluation of cerebral function by mini-mental-state examination was done.

Results
There were no significant differences between the study group (radical prostatectomy) and the control group (partial nephrectomy) concerning cerebral oxygenation, cerebral hemodynamics and cerebral function.

Conclusions
Extreme (45 degrees) Trendelenburg position seems to do no harm concerning cerebral function to the patients undergoing robot-assisted radical prostatectomy even in longer (up to 5 hours) operating time.

Date & Time: May 18, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Robotics – Benign & Malignant Disease
Sources of Funding: none

Sunday, May 18, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
Technology & Instruments: Robotics – Benign & Malignant Disease
Funding: University of Washington Department of Urology; University of Washington School of Medicine
MP37-05: THE DA VINCI ROBOT TRAINING DILEMMA: EVALUATING THE RAVEN ROBOT AS A SOLUTION 
Deanna Glassman*, Lee White, Andrew Lewis, Hawkeye King, Alicia Clarke, Thomas Glassman, Bryan Comstock, Blake Hannaford, Seattle, WA, Tim Brand, Tacoma, WA, Thomas S. Lendvay, Seattle, WA

Abstract: MP37-05
Introduction and Objectives
Robotic assisted surgery is being rapidly adopted as evidenced by a 25% growth rate in the number of robotic procedures performed in the last four years. This progression is challenging the ability of surgeons to receive adequate training on robotic systems and keep up with the demand. The limited availability of the da Vinci robot for training has increased the need for new training tools. The Raven robot, a more compact system that is almost 1/10th the cost of a da Vinci robot, may provide a solution to the training demand. The purpose of this study was to determine whether training on the Raven robot would be non-inferior to training on the da Vinci robot for the Fundamentals of Laparoscopic Surgery (FLS) block transfer task.Methods
A total of 30 medical students were enrolled and were randomly assigned to Raven training (RT) or da Vinci training (DT). Both groups practiced to proficiency on their assigned robot for the FLS block transfer and subsequently completed a criterion test on the da Vinci robot during a separate session.

Results
Upon completion of robotic FLS block transfer proficiency training, there were no statistically significant differences between path length (p=0.39) or economy of motion (EOM) (p=0.06) between the two groups. The RT group had an average path length of 355 ± 44 in and the DT group averaged 339 ± 49 in (p = 0.39, 95% CI -1.56 to 33.31. The average EOM for the RT and DT groups was 3.74 in/s ± 0.99 and 4.43 in/s ± 0.83, respectively (p = 0.06, 95% CI -1.04 to -0.33). Video review of the criterion tasks were performed by a panel of experienced robotic surgeons to provide a composite performance score using a validated structured technical skills assessment tool for robotics, the Global Evaluative Assessment of Robotic Skills (GEARS), and it was observed that scores were not statistically different between the two groups (p=0.87, 95% CI 19.4 to 20.8). Out of the five GEARS domains assessed, only efficiency ratings were higher in the DT group than the RT group (p=0.04). This was expected given that this domain incorporates speed as a marker and the DT group had faster task times. When asked about the value that Raven training had on their ability to perform on the da Vinci robot, RT subjects cited strong scores, an average of 4.8 out of 5.0.

Conclusions
This prospective randomized trial provided evidence for the value of using the Raven robot for training prior to using the da Vinci system for similar tasks.

Date & Time: May 18, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Robotics – Benign & Malignant Disease
Sources of Funding: University of Washington Department of Urology; University of Washington School of Medicine

 

Sunday, May 18, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
Technology & Instruments: Robotics – Benign & Malignant Disease
Funding: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Cancer Institute, Center for Cancer Research, and the Center for Interventional Oncology. NIH and Philips Healthcare have a cooperative research and development agreement. NIH and Philips share intellectual property in the field. This research was also made possible through the National Institutes of Health Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and generous contributions to the Foundation for the NIH from Pfizer Inc., The Doris Duke Charitable Foundation, The Alexandria Real Estate Equities, Inc. and Mr. and Mrs. Joel S. Marcus, and the Howard Hughes Medical Institute, as well as other private donors. For a complete list, please visit the Foundation website at: http://fnih.org/work/education-training-0/medical-research-scholars-program
MP37-06: Multiparametric Magnetic Resonance Imaging and MRI/Ultrasound Fusion-Guided Biopsy Stratify Patients at Risk for Extracapsular Extension at Radical Prostatectomy 
Dima Raskolnikov*, Arvin George, M. Minhaj Siddiqui, Soroush Rais-Bahrami, Baris Turkbey, Chinonyerem Okoro, Jason Rothwax, Nabeel Shakir, Annerleim Walton-Diaz, Daniel Su, Lambros Stamatakis, Maria Merino, Bradford Wood, Peter Choyke, Peter Pinto, Bethesda, MD

Abstract: MP37-06
Introduction and Objectives
In patients with prostate cancer (CaP), preoperative identification of extracapsular extension (ECE) can provide vital information for the surgical planning of robot-assisted radical prostatectomy (RARP). Historically, MRI has had limited sensitivity for ECE. We aim to evaluate which parameters on multiparametric MRI (MP-MRI) and MRI/ultrasound (MRI/US) fusion-guided biopsy aid in the pre-operative assessment of ECE.Methods
Between May 2007 and August 2013, 299 patients at our institution underwent 3T MP-MRI, MRI/US fusion-guided biopsy with standard 12-core biopsy, and RARP. Visualized lesions were identified as low, moderate, or high suspicion for CaP according to the previously validated NIH scoring system. Findings were characterized as “presence of ECE,” “extracapsular bulge,” or neither. MP-MRI findings were correlated with biopsy results, final RARP pathology and margin status. Univariate analysis was performed to evaluate pre-operative predictors of ECE on final pathology.

Results
MRI was positive for ECE in 27 patients and negative in 272, with a sensitivity of 17.2% and a specificity of 93.2% when compared to final pathology. In all patients, the rate of positive surgical margins was 15.1%. This rate increased to 22.2% in the subset of patients with MRIs that were positive for ECE, but increased to 31.1% in those patients whose MRIs were false negatives. In the group of patients with negative MRIs, PSA, MRI suspicion score, presence of bulge, and highest Gleason score on MRI/US fusion-guided biopsy were all associated with ECE on final pathology (p<0.001, Table). This was not the case for standard 12-core biopsy.

Conclusions
When ECE is correctly identified on MRI, margin involvement increases slightly as compared to that seen with low risk CaP. However, margin involvement increases much more substantially when the final pathology report of ECE was unexpected due to a false negative MRI. In the absence of visible ECE on MP-MRI, the lesion suspicion score, presence of extracapsular bulge, and Gleason score on MRI/US fusion-guided biopsy can help identify those patients who are most likely to harbor ECE. This may guide pre-operative surgical planning and reduce the occurrence of positive surgical margins after RARP.

Date & Time: May 18, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Robotics – Benign & Malignant Disease
Sources of Funding: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Cancer Institute, Center for Cancer Research, and the Center for Interventional Oncology. NIH and Philips Healthcare have a cooperative research and development agreement. NIH and Philips share intellectual property in the field. This research was also made possible through the National Institutes of Health Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and generous contributions to the Foundation for the NIH from Pfizer Inc., The Doris Duke Charitable Foundation, The Alexandria Real Estate Equities, Inc. and Mr. and Mrs. Joel S. Marcus, and the Howard Hughes Medical Institute, as well as other private donors. For a complete list, please visit the Foundation website at: http://fnih.org/work/education-training-0/medical-research-scholars-program

 

Sunday, May 18, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
Technology & Instruments: Robotics – Benign & Malignant Disease
Funding: “none”
MP37-07: Comparative effectiveness of robotic-assisted versus open radical prostatectomy cancer control outcomes 
Ioana Popa*, Montreal, Canada, Jim C. Hu, Los Angeles, CA, Giorgio Gandaglia, Jonas Schiffmann, Mounsif Azizi, Vincent Trudeau, Nawar Hanna, Montreal, Canada, Quoc-Dien Trinh, Boston, MA, Pierre I Karakiewicz, Maxine Sun, Montreal, Canada

Abstract: MP37-07
Introduction and Objectives
Robotic-assisted surgery remains controversial due to exaggerated marketing claims, higher costs, hidden risks and few clinically significant benefits; no improvement in radical prostatectomy (RP) cancer control outcomes have been demonstrated to date. The purpose of our study is to examine the population-based, comparative effectiveness of robotic-assisted RP RARP versus open RP (ORP) for surgical margin status and use of additional cancer therapy.Methods
We identified 13,434 men with a histologically confirmed, non-metastatic prostate cancer treated with RARP versus ORP during 2004 and 2009 from Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data. Propensity-based analyses were performed to minimize treatment selection biases. Generalized linear regression models were computed for comparison of RP surgical margin status and use of additional cancer therapy (radiation and/or androgen deprivation therapy) by surgical approach.

Results
During the study period, 5,556 and 7,878 men underwent RARP and ORP, respectively. In the propensity-adjusted cohort, the incidence of positive surgical margins was significantly lower among men undergoing RARP versus ORP (13.7% vs. 18.4%, odds ratio [OR]: 0.68, 95% confidence interval [CI]: 0.63–0.73, p<0.001), and this was driven by differences in intermediate (15.1% vs. 21.7%; OR 0.66; 95%CI 0.58–0.74) and high-risk (15.1% vs. 21.7%; OR 0.69, 95%CI 0.64–0.75) disease. Additionally, RARP was associated with less use of additional cancer therapy within 6 (4.7% vs. 6.6%; OR 0.74; 95%CI 0.66, 0.82), 12 (OR 0.74 95%CI 0.63, 0.86) and 24 (OR 0.68; 95%CI 0.58–0.79) months of surgery.

Conclusions
Despite controversial adoption and higher costs, robotic-assisted surgery was associated with improved surgical margin status relative to ORP among men with intermediate and high-risk disease. This has important implications for patient quality of life, health care delivery and costs particularly with greater acceptance of active surveillance for low-risk disease and greater adoption of adjuvant radiotherapy for positive surgical margins, consistent with level-one evidence.

Date & Time: May 18, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Robotics – Benign & Malignant Disease
Sources of Funding: “none”

 

Sunday, May 18, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
Technology & Instruments: Robotics – Benign & Malignant Disease
Funding: None
MP37-08: Robot assisted Video Endoscopic Inguinal Lymphadenectomy: Our single centre experience of complications and outcome analysis 
Amit Goel*, Anish Gupta, Samir Khanna, Saurabh Vashishtha, Sudhir Rawal, Delhi, India

Abstract: MP37-08
Introduction and Objectives
Inguinal Lymphadenectomy is the standard of care for metastatic nodal disease in cases of Penile, Urethral, Vulval and Vaginal Cancers. Outcomes, including cure rates, overall and progression free survivals have progressively improved in these diseases with extending criteria to offer inguinal lymph node dissection for patients ‘at-risk’ for metastasis or loco-regional recurrence. Open Inguinal node dissection is associated with significant post operative morbidity. We report our experience with robot assisted video endoscopic inguinal lymphadenectomy(RA-VEIL) in patients and assess the incidence and magnitude of complications and outcomes.Methods
From March 2011 to July 2013 we performed 81 RA-VEIL on 43 patients. 34 were males for penile cancer and 9 females for vulval cancer.38 patients underwent simultaneous bilateral RA-VEIL and 10 patients also had simultaneous robot assisted pelvic lymphadenectomy in view of metastatic inguinal nodal disease. Complications were divided into minor and major, and early (30 days or less after surgery) and late (greater than 30 days), and analyzed. Minor complications were defined as mild to moderate leg edema, seroma formation, focal skin necrosis requiring no therapy and cellulitis managed with antibiotics. Major complications included death, sepsis, venous thromboembolism, severe leg edema interfering with ambulation, skin flap necrosis and rehospitalization. All patients had completed minimum 90 days of followup.

Results
RA-VEIL was successful in all patients without any open conversion. Median body mass index 30 kg/m2 (range 19 to 38, mean 31.1), median age 50 years (range 29 to 72), and median length of stay 3 days (range 3 to 10). The average operative time and average blood loss for single groin was 80 min and 70 ml, respectively . There were no intra operative complications. The average single groin lymph node retrieval rate was 14. All patients were ambulated from day 1. Most patients were discharged by day 3 with drain in-situ. Average time for drain removal was 12 days. A total of 32(39.5%) minor complications occurred within 30 days (18 groins developed seromas necessitating repeated aspiration and compressive dressings, 10 groins had focal superficial skin flap necrosis, 4 developed wound infections) and 22(27.1%) minor complications after 30 days ( lymphedema in 17 limbs and 5 limbs developed cellulitis). 2(0.02%) groins had skin flap necrosis at site of camera port.

Conclusions
Robotic assisted VEIL is a feasible, safe procedure with minimal morbidity and good oncological outcomes

Date & Time: May 18, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Robotics – Benign & Malignant Disease
Sources of Funding: None

Source: AUA 2014

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