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We determined the necessary extent of pelvic lymph node dissection in patients with strictly unilateral bladder cancer.A total of 40 patients with cystectomy and unilateral bladder cancer preoperatively underwent flexible cystoscopy guided injection of radioactive technetium into the contralateral bladder wall. Preoperatively single photon emission computerized tomography was done in all cases to detect and localize radioactive lymph nodes. Radioactive lymph nodes were confirmed intraoperatively by a γ probe and removed separately. Backup extended pelvic lymph node dissection and ex vivo examination of the whole specimen with a γ camera were done to preclude missed radioactive lymph nodes. Single photon emission computerized tomography and intraoperative findings were used to generate a 3-dimensional projection model of each lymph node site.A total of 228 radioactive lymph nodes (median 6, range 1 to 17) were detected, including 193 (85%) on the ipsilateral side of injection and 35 (15%) on the contralateral side. Of the contralateral lymph nodes 6%, 5% and 4% were in the external iliac, obturator fossa and common iliac region, respectively, but none were in the contralateral internal iliac region. At least 1 radioactive lymph node per patient was detected on the ipsilateral side. Additional lymphatic drainage to the contralateral side was found in 40% of patients.Crossover lymphatic drainage is a common phenomenon and unilateral pelvic lymph node dissection would have missed radioactive lymph nodes in 40% of patients. However, we noted no lymphatic drainage to the contralateral internal iliac region. Thus, when bladder tumors are strictly unilateral, contralateral pelvic lymph node dissection can be limited to the obturator fossa, and the external and common iliac regions. Consequently preserving the contralateral autonomic nerves situated close to the internal iliac vessels does not compromise surgical radicality.

We evaluated the face, content and construct validity of the novel da Vinci® Skills Simulator™ using the da Vinci Si™ Surgeon Console as the surgeon interface.We evaluated a novel robotic surgical simulator for robotic surgery using the da Vinci Si Surgeon Console and Mimic™ virtual reality. Subjects were categorized as novice-no surgical training, intermediate-surgical training with fewer than 100 robotic cases or expert-100 or more primary surgeon robotic cases. Each participant completed 10 virtual reality exercises with 3 repetitions and a questionnaire with a 1 to 10 visual analog scale to assess simulator realism (face validity) and training usefulness (content validity). The simulator recorded performance based on specific metrics. The performance of experts, intermediates and novices was compared (construct validity) using the Kruskal-Wallis test.We studied 16 novices, 32 intermediates with a median surgical experience of 6 years (range 1 to 37) and a median of 0 robotic cases (range 0 to 50), and 15 experts with a median of 315 robotic cases (range 100 to 800). Participants rated the virtual reality and console experience as very realistic (median visual analog scale score 8/10) while expert surgeons rated the simulator as a very useful training tool for residents (10/10) and fellows (9/10). Experts outperformed intermediates and novices in almost all metrics (median overall score 88.3% vs 75.6% and 62.1%, respectively, between group p0.001).We confirmed the face, content and construct validity of a novel robotic skill simulator that uses the da Vinci Si Surgeon Console. Although it is currently limited to basic skill training, this device is likely to influence robotic surgical training across specialties.

main renal artery was clamped with an early unclamping (unclamping after one or two running suture in the tumor bed but before parenchymal repair). In the second case, a 4 cm totally endophytic tumor of the left kidney arised in a 66 year-old male. RENAL NEPHROMETRY score was 9-h. An off-clamp technique was chosen. RESULTS: In the first case, warm ischemia time was 24 minutes and estimated blood loss was 500 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 5. Surgical margins were negative. At 1 month postoperatively, 88% of renal function was preserved. In the second case, an important bleeding occurred during tumorectomy. First, the surgeon switched to a selective arterial clamping. The bleeding continued and the surgeon had to clamp the main renal artery. Warm ischemia time was 8 minutes and estimated blood loss was 1200 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 4. Surgical margins were negative. At 1 mont postoperatively, 86% of renal function was preserved. CONCLUSIONS: Hilar tumors are good candidates for the “zero ischemia” techniques during robotic partial nephrectomy. However, they could lead to important bleeding that could increase the surgical morbidity and the risk of positive margins. As recent data suggest that a limited warm ischemia time (< 30 minutes) could have no impact on renal function, the early unclamping technique, which appear safer, could be the preferred option in these patients.

INTRODUCTION AND OBJECTIVES: To use single photon emission computed tomography (SPECT) combined with computed tomography (CT) plus intraoperative gamma probe verification to map the primary lymphatic landing sites of the of the lateral bladder wall. METHODS: Clinical trial of 40 consecutive cystectomy patients with unilateral bladder cancer ( cT3, cN0, cM0) at a single center. One day prior to surgery flexible cystoscopy-guided injection of Tc-99m nanocolloid into the non-tumor-bearing lateral bladder wall (left: n 21; right: n 19) was performed. All patients underwent SPECT-CT 3 and 6 h after injection of the radiopharmaceutical with a bladder flushing catheter in place. The SPECT-CT detected radioactive lymph nodes (LNs) were confirmed intraoperatively with a gamma probe at the time of PLND. Radioactive LNs were removed separately. A backup extended PLND was performed to preclude missed primary lymphatic landing sites. The SPECT-CT and intraoperative findings were used to generate a three-dimensional projection of each LN site. RESULTS: A total of 1655 LNs (median 39 LNs per patient; range 21–83) were resected. 228 of these were radioactive (median 6 radioactive LNs per patient; range: 1–17). 193 radioactive LNs (85%) were located on the ipsilateral side of the injection and 35 (15%) on the contralateral side (external iliac 6%, obturator fossa 5%, common iliac 4%), but none in the internal iliac region. Only 11% of radioactive LNs were located cephalad to the uretero-iliac crossing. All patients had at least 1 radioactive LN on the ipsilateral side. 40% of patients had at least 1 additional radioactive LN on the contralateral side. CONCLUSIONS: A unilateral PLND would have missed radioactive LNs on the contralateral side in 40% of patients. Therefore, a bilateral extended PLND including the common iliac region up to the uretero-iliac crossing is mandatory even in strictly laterally localized bladder tumors. Still, we could not detect any radioactive LNs in the contralateral internal iliac region. Therefore, contralateral PLND may be limited to the obturator fossa, external iliac and common iliac region which has influence on nerve sparing in patients who are candidates for an ileal bladder substitute.

INTRODUCTION AND OBJECTIVES: To evaluate the face, content, and construct validity of a novel robotic surgical simulator platform utilizing the da Vinci® Si surgeon console. METHODS: Intuitive Surgical (Sunnyvale, CA) has developed a novel skills simulator for robot-assisted surgery, utilizing the da Vinci® Si surgeon console and virtual reality software designed in collaboration with Mimic Technologies (Seattle, WA). Participants were enrolled in a prospective, institutional review board-approved study. Subjects were categorized as novice (no surgical training), intermediate (surgical training but not expert robotic surgeon), or expert robotic surgeon ( 100 cases as primary surgeon). Each completed 10 virtual reality exercises with 3 repetitions. Tasks were designed to train/assess camera control and clutching, Endowrist manipulation, needle control, and needle driving. Each participant completed a post-study questionnaire (based on a 1–10 scale) to assess realism of simulator (face validity) and utility as a teaching tool (content validity). The simulator recorded participant performance based on specific metrics. Performance metrics of experts, intermediates and novices (construct validity) were compared using the Kruskal-Wallis test. RESULTS: The novice cohort (n 17) were medical students. The intermediate cohort (n 23) were residents, fellows, and attending surgeons (median surgical experience 5.3 years (range 1–37) who had performed a range of 0-50 robotic console cases (median 0). The expert cohort (n 14) were a multi-disciplinary group of surgeons (urology, cardiothoracic, gynecology) who had performed a range 100-800 robotic cases (median 300). Participants rated the virtual reality and console experience as very realistic (median score 8/10), and expert surgeons rated the simulator as a useful training tool for residents (median 10/10) and fellows (9/10). Experts out-performed novices in almost all metrics (see Table), and intermediates in essential metrics. CONCLUSIONS: The initial study evaluating the face, content, and construct validity of a novel robotic simulator platform is presented. Importantly, we elucidated a difference between intermediate and expert surgeons on key parameters, identifying relevant points along the learning curve for robotic surgery.