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Objectives: Open pyeloplasty is the standard treatment for ureteropelvic junction obstruction in children. The introduction of robotic surgical system has facilitated precise intracorporeal suturing and shortened the learning curve for minimal invasive procedures for the surgeons. There is sparse data over the outcomes of robot-assisted laparoscopic pyeloplasties in children. We describe our technique and outcomes of robotic pyeloplasty in children., Patients and Methods: Operative data for all patients undergoing a robot-assisted procedure at our center is prospectively recorded in a database. We retrieved data of patients below the age of 16 years undergoing robot-assisted pyeloplasty between July 2007 to March 2011 and evaluated their operative parameters, recovery, and functional outcomes., Results: In the period under review, 34 pediatric patients (mean age 12 years, range 5-15 years) underwent robot-assisted laparoscopic pyeloplasty at our center. All patients underwent unilateral pyeloplasty but one patient underwent a simultaneous contralateral pyelolithotomy. The mean total operative time (range) was 105 minutes (75-190 minutes), average dissection time and the anastomosis time was 23 minutes (20-58 minutes) and 46.5 minutes (28-70 minutes) respectively. The mean blood loss was 30 mL. Follow-up of 36, 24, 18, 12, and 6 months was completed in 14, 21, 24, 28, and 31 patients respectively. Postoperatively, one patient had an omentum herniation through the camera port site and another had an ileocaecal volvulus. With a mean follow-up of 28.5 months (2-56 months), the success rate was 97% (32/33), whereas postoperatively one patient had deterioration of function., Conclusion: Robot-assisted laparoscopic pyeloplasty is a safe and effective minimally invasive treatment modality in children.

Objectives: Advancement in technology has led to a decrease in invasiveness for surgical management of malignant renal neoplasms. Laparoscopic radical nephrectomy is an established treatment for renal tumors. Since the introduction of robotic surgery in the realm of urology, many procedures have been done robotically. We evaluated the feasibility, safety, and oncological outcomes of robotic radical nephrectomy (RRN)., Methods: We retrospectively reviewed the records of patients who underwent RRN for renal tumors at our institute from September 2007 to March 2011. Patients with standard indications for a radical nephrectomy were offered a robot-assisted procedure. Intraoperative parameters (operative time, blood loss, transfusion of blood products), postoperative parameters and complications were recorded., Results: Twenty-three patients who underwent RRN were included. Mean operative time was 132.7 min and mean blood loss 270 ml. The majority of patients were able to tolerate liquid diet, were free from drain, and were fit for discharge by postoperative day (POD) 1, POD 2 and POD 3, respectively. After the mean follow-up of 29.4 months, no patient had residual tumor, local recurrence or metastasis., Conclusion: We conclude that RRN is a feasible and safe procedure with good oncological outcome on short-term follow-up., (Copyright © 2012 S. Karger AG, Basel.)

Objective: • To critically analyze and compare surgical, oncological and functional outcomes of robot-assisted radical prostatectomy (RARP) in patients with and without previous transurethral resection of prostate (TURP)., Patients and Methods: • The study comprised 158 cases of RARP for clinically localized prostate cancer, including 26 cases that had undergone previous TURP (Group A). • Surgical, oncological and functional (short- and intermediate-term) outcomes of Group A were compared with 132 cases without previous TURP (Group B)., Results: • Post TURP patients were found to have significantly greater blood loss (494 vs 324 mL) and a need for bladder neck reconstruction (26.7% vs 9.7%) compared to the non-TURP group. • Surgical time (189 vs 166 min), conversion rate, margin positivity rate and biochemical recurrence rate were also higher. • Incontinence rates were higher both at 6 (14% vs 11.8%) and 12 (25% vs 8%) months follow-up., Conclusions: • RARP is feasible but challenging after TURP. It entails a longer operating time, greater operative difficulty and compromised oncological or continence outcomes. • These cases should be handled by an experienced robotic surgeon with the appropriate expertise., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Objectives: To present our experience and outcomes of robot-assisted laparoscopic surgery (RALS) performed for different ureteral pathologies and to discuss the true utility of robotics in ureteral surgery., Methods: We reviewed a total of 44 procedures performed for diverse ureteral pathologies involving the proximal and distal ureter in 2 institutions from July 2006 to July 2009. Operative time, blood loss, length of stay, complications, and subjective and objective follow-up were evaluated., Results: The 44 cases included 18 distal ureteral procedures including 5 distal ureterectomy with ureteroneocystostomy; 1 ureteroneocystostomy with psoas hitch; 2 ureteroneocystostomy with vesicovaginal fistula repair; 9 megaureter repairs in 8 cases; there were 12 proximal ureteral procedures including 7 ureteroureterostomies and 4 retrocaval ureter repairs; 10 ablative procedures consisting of 5 nephroureterectomies with cuff of bladder and 5 nephroureterectomies and 4 miscellaneous procedures. The mean operative time was 137.9 minutes (range: 70-240). Mean blood loss was 98.2 mL (range: <50-400). There were no urine leaks. Mean drain tube duration was 1.4 days (range: 1-2.5) and mean hospital stay was 2.4 days (range: 1-6). Complications included 1 case of sepsis and 1 antibiotic-induced infection. Average follow-up period was 13.5 months. Operative success as defined by symptom resolution and imaging was 100%., Conclusions: RALS is feasible, safe, and an effective option for ureteral pathologies at any level of the ureter with minimal peri-operative morbidity. However, appropriate port placement, patient positioning, and versatile experience of team is critical in handling such cases for better outcomes., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Introduction: Recurrence of fistula is one of the very common complications of fistula repair. The disease has immense psychosomatic effect on the patients due to continuous leakage of urine. Management of recurrent vesico-vaginal fistula (VVF) repair poses a challenge to surgeons., Materials and Methods: Group I-12 patients with recurrent VVF, having robotic repair from August 2006 to June 2008, were included in the present study. Group II-20 patients matched in all possible parameters with recurrent VVF having open surgical repair in the past were taken as controls. Patients in both the groups were evaluated by assessing relevant clinical details; performing urine routine examination and culture, renal function test, three swab test, ultrasonogram-kidney, ureter, and bladder radiograph, intravenous urogram (to look for upper tract and rule out uretero-vaginal fistula), and urethro-cystoscopy. The details were retrospectively recorded from the case sheets., Results: In group I, 100% were successfully managed as compared with 90% in group II, but it was not statistically significant (p > 0.05). Mean blood loss was significantly less (p < 0.05) in group I compared with group II (mean 88 vs. 170 mL). The mean hospital stay also was significantly less (p < 0.05) in group I in comparison with group II (mean 3.1 vs. 5.6 days). None of the patients had complications in group I compared with group II, but it was not significant., Conclusion: The present study suggests that robotic VVF repair is a better option for recurrent fistulas in view of its reduced morbidity, without compromising the results.

Purpose: To assess the feasibility and outcomes of robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO)., Methods: Complicated UPJO cases included patients with the following: concomitant multiple or calyceal stones, secondary UPJO (post-ureteroscopy, open or percutaneous surgery), malrotated kidney, horseshoe kidney, ectopic kidney, giant hydronephrosis, poorly functioning kidney (glomerular filtration rate <20 ml/min), non-redundant renal calyces (requiring nephroplication), ptosis of the kidney (requiring nephropexy), long stricture (>2 cm), age <5 or >60 years and duplex pelvis. All cases underwent dismembered robotic pyeloplasty. Data were collected for operative time, blood loss, stone clearance, analgesic usage and time to recovery. Follow-up was done with intravenous urography and dynamic renal scan., Results: A total of 29 cases underwent dismembered robotic pyeloplasty with an average operative time and blood loss of 130 min and 50 ml. Stone clearance could be achieved in 8 out of 10. The average follow-up period was 15 months with a symptomatic and objective success rate of 96.6% (28/29). No perioperative complications were noted., Conclusions: Robotic pyeloplasty for complicated cases of UPJO is feasible, safe and effective, and has a durable success rate.

Objective: Early results indicate that robot assisted laparoscopic surgery (RALS) may be useful in managing upper tract (UT) urolithiasis. We reviewed our experience of managing 50 cases of UT urolithiasis with or without reconstruction using RALS., Materials and Methods: We performed a record review of 50 cases of RALS for UT urolithiasis performed in two institutions from July 2006 to June 2009. The RALS procedures included pyeloplasty with pyelolithotomy (29 cases), ureterolithotomy, tailoring and reimplantation for megaureters (5 cases), ureterolithotomy with ureteral stricture reconstruction (1 case), primary UT stone surgeries (8 cases), partial nephrectomy (1 case) and ablative surgeries (6 cases). Data pertaining to indications, operative details, and complications were analyzed., Results: The average operating time was 105 min (86 min-135 min) for pyeloplasty with pyelolithotomy, 140 min (115 min-195 min) for ureterolithotomy, tailoring and ureteroneocystostomy and 106 min (88 min-174 min) for extended pyelolithotomy (5 cases). Mean blood loss was 77 mL (50 mL-250 mL). Stone clearance rate was 93.2%. One case of extended pyelolithotomy had hematuria requiring selective angioembolization. There was one conversion and no other major complication., Conclusions: RALS for UT urolithiasis is safe and efficacious. It is particularly useful when stone removal is combined with reconstruction. It is a reasonable alternative for treating a solitary partial staghorn or a large pelvic stone including those in pelvic/anomalous kidneys. RALS did not seem substantially better than pure laparoscopy for isolated ureterolithotomy and for nephrectomy for a nonfunctioning kidney. Its role in the treatment of large, multiple or complete staghorn calculi needs further investigation.

Objective: To record the technical problems and complications associated with the use of da Vinci S robotic system (Intuitive Surgical, Sunnyvale, CA, USA) and to review previous reports., Methods: We analysed our records for all machine- or instrument-related errors during the course of 340 consecutive robot-assisted urological operations at our centre from July 2006 to March 2009, using one robotic machine. The cause of the error (machine or human), troubleshooting methods and consequences of the errors were evaluated., Results: The overall device failure rate was 10.9% (37/340). The most frequent technical problems were related to robotic instruments (23/37). Other failures included colour/hue changes in the console image, intermittent double vision, fused illuminator bulb and problems with the master tool-manipulator device (hand-piece unit), patient cart circuitry, patient-side manipulator arm, closed-circuit camera unit or camera cable. Of 37 problems, 28 (76%) were surmountable during the course of surgery. The overall conversions to standard open/laparoscopic procedure attributable to mechanical failures of the robot were 0.6% (2/340). There were no complications or direct harm to the patient in any case. Most faults could be corrected or bypassed with some addition to operating room time., Conclusions: Despite an association of various types of new technical problems with robotic surgery, it provides a safe mode of minimally invasive surgery with very low conversion rates attributable to it, and no direct patient injury.

Purpose: To assess the feasibility, describe the technique, and report our experience with use of the da Vinci S robotic surgical system in the management of pheochromocytoma., Patients and Methods: For four patients with metabolically active adrenal pheochromocytoma (two right, two left), standard preoperative preparation was performed. A robotic transperitoneal approach was used for all cases. Sparing of the adjacent normal parenchyma was performed in all cases. All relevant perioperative details were collected and analyzed., Results: Mean operative time was 77.5 minutes (range 40-140 min), and blood loss was 97.5 mL (range 50-160 mL). There were no conversions or perioperative complications. Average tumor size was 4.7 cm. There were three episodes of intraoperative hypertension necessitating therapeutic intervention. Average analgesic requirement was 150 mg of diclofenac, and patients were allowed oral intake after 6 hours. The drain was removed within 24 hours, with average hospital stay of 4 days. The histopathology report confirmed pheochromocytoma in all patients with free surgical resection margins. Average follow-up was 9 months (range 4-14 mos) with no evidence of recurrence or extra-adrenal tumor., Conclusion: Robot-assisted excision of pheochromocytoma is feasible, safe, and efficacious in our early experience. Sparing of the normal adjacent adrenal parenchyma is possible with little detrimental effect on the oncologic efficacy of the surgery. Long-term studies are needed to further confirm this issue.

Pheochromocytoma of the urinary bladder is rare, presenting usually with hypertension, hematuria and syncopal attacks. Such cases have usually been managed with open or laparoscopic partial cystectomy. We present a case of bladder pheochromocytoma that had unusual presenting symptoms, a paraneoplastic manifestation and was successfully managed with robotic technique.

Objective: To present our experience and outcomes of robot-assisted laparoscopic pyeloplasty (RALP) for pelvi-ureteric junction obstruction (PUJO)., Patients and Methods: This was a prospective study of 85 consecutive patients who had RALP for PUJO at our institute from July 2006 to December 2008. The preoperative evaluation included intravenous urography (IVU) and diuretic renography. The type of pyeloplasty was decided based on the size of the pelves, presence of crossing vessel, level of ureteric insertion and the length of obstruction. All surgery was done through a transperitoneal approach using four or five ports. The follow-up comprised IVU and renal dynamic scintigraphy. Relevant data were collected and analysed for perioperative morbidity, complications and long-term functional outcomes., Results: In all, 86 RALPs were performed, including one bilateral, 41 right-sided and 43 left-sided cases. The mean operative time was 121 min, including an anastomosis time of 47 min. The mean estimated blood loss was 45 mL. The drain was removed within 48 h. The mean hospital stay was 2.5 days. Three patients had stents that migrated upwards, and prolonged drainage. The success rate was 97% (82/85) with a mean follow-up of 13.6 months., Conclusions: RALP is highly effective for managing PUJO, with low morbidity, quick recovery and a durable success rate.

Ectopic pelvic kidneys with ureteropelvic junction obstruction and stones present a treatment challenge for the minimally invasive surgeon. A pure laparoscopic approach is less invasive than an open approach but is technically difficult with longer operative time. The use of the da Vinci robotic interface has the potential to refine the laparoscopic technique and improve outcomes. Here, we present successful management using the robotic technique of one such case of concomitant pyeloplasty and pyelolithotomy.

Purpose: To demonstrate the technical feasibility of the transmesocolic approach of robotic pyeloplasty for left ureteropelvic junction obstruction (UPJO)., Patients and Methods: Between July 2006 and December 2007, 60 patients underwent robot-assisted pyeloplasty that included 33 cases on the right side and 27 cases on the left side. Of the 27 left-side cases, 24 were performed using a transmesocolic approach. Three left-side surgeries were performed by mobilizing the colon because of associated accessory vessel and renal calculi. A pure robot-assisted dismembered reduction pyeloplasty with excision of the ureteropelvic junction was performed in all cases., Results: The mean operative time was 125.33 minutes. The time to perform the anastomosis was 43.58 minutes, and mean blood loss 38.7 mL. Average hospital stay was 2.5 days, and the drain was removed within 48 hours. One patient had prolonged drainage with fever because of a misplaced ureteral stent. Of the 24 patients, 23 were followed for 1 year and 1 was lost to follow-up. No patient demonstrated clinical or radiographic evidence of repeated obstruction., Conclusion: In the transmesocolic approach, mobilization of the colon is not necessary, and the UPJO can be approached directly after incising the mesocolon. This approach is safe and feasible in patients with a thin mesentry and when extensive mobilization of the kidney is not needed for any associated problems. The technique is highly effective with durable success rates similar to those of open surgery.

Purpose: To evaluate the feasibility and safety of two concomitant robot-assisted procedures in the same patient in one anesthesia setting., Patients and Methods: Data were reviewed for 15 patients for whom two concomitant robot-assisted surgeries at our center were planned. Preoperative details, port position, intraoperative problems encountered, surgical and anesthesia time, blood loss, complications, hospital stay, and postoperative recovery were analyzed., Results: Fifteen patients underwent two concomitant robot-assisted procedures; at least one of the two surgeries was a urologic procedure. The second procedure added <50 mL of blood loss. Surgical time was increased by 58 minutes and 30 minutes in cases in which the primary procedure involved the upper and lower urinary tract, respectively, while anesthesia time was increased by 82 minutes and 30 minutes, respectively. There were no added complications during the second procedure, and hospital stay was not increased, being limited only by the first procedure., Conclusion: Planned robot-assisted surgery for two different operations is feasible in one anesthesia session, thereby reducing cost and overall hospital stay for the patient without any increased risk of perioperative morbidity. The decision to continue with the second procedure depends on the successful completion of the first procedure in a reasonable time and without any complications.

Introduction: Urinary continence is an important outcome parameter after robot assisted radical prostatectomy (RARP). We evaluated the continence outcomes following RARP using a double-layered urethrovesical reconstruction. Materials and Methods: One hundred fifty consecutive patients undergoing RARP and double-layered urethrovesical reconstruction were prospectively studied for preoperative, intraoperative and post operative parameters. Key points followed during surgery were: Minimal dissection of sphincteric complex, preservation of puboprostatic ligament, selective ligation of deep venous complex and both posterior and anterior reconstruction using the Von Velthoven stitch. Intraoperative bladder fill test was done at the end of anastomosis to rule out urine leak. Check cystogram was done prior to catheter removal in the outpatient department. Patients were subsequently followed at regular intervals regarding the status of urinary continence. All patients irrespective of adjuvant therapy were included in the analysis. Results: The mean age was 64 years (standard deviation ± 6.88), and mean serum PSA was 20.2 ng/ml. The mean BMI was 25.6 (SD: ±3.84). The mean prostate weight was 44.09 gm (range 18-103 gm, SD: ±15.59). Median days to catheter removal after surgery was 7 (range 4-14 days) days. Cystographically determined urinary leaks were seen in two patients. Urine leak was managed by delaying catheter removal for 1 week. Minimum 6 month follow up was available in 126 patients. 'No pad' status at 1 week, 1 month, 3 months, 6 months and 1 year was 15.1%, 54.9%, 78%, 90.5% and 94.1%, respectively. Conclusion: Excellent continence outcomes are observed in patients undergoing double-layered urethrovesical reconstruction. [ABSTRACT FROM AUTHOR]

The author reflects on the significance of the contributions of Dr. Patrick Walsh on the anatomic dissection for preservation of the neurovascular bundles (NVBs), making radical prostatectomy (RP) the treatment of choice for patients with clinically localized prostate cancer and life expectancy of more than 10 years. Topics discussed include the unpopularity of laparoscopic radical prostatectomy (LRP) when launched in 1994, the different scene in India, and the other issues concerning RP.