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Autorino R.,Cleveland Clinic | Autorino R.,The Second University of Naples | Zargar H.,Cleveland Clinic | White W.M.,Urologic | And 7 more authors.
Urology | Year: 2014

Herein, we provide a systematic review and critical analysis of the current evidence on the applications of near-infrared fluorescence in robotic urologic surgery. Article selection proceeded according to Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Overall, 14 studies were identified and included. Indocyanine green fluorescence imaging system has been tested for several applications, robotic partial nephrectomy representing the most studied one. Available evidence suggests this technology can be of aid in visually defining the surgical anatomy, thus ultimately facilitating the task of the console surgeon. Whether the added cost is justified by better outcomes remains to be determined. © 2014 Elsevier Inc. All rights reserved.

Buse S.,Urologic | Buse S.,University Hospital of Frankfurt | Hach C.E.,Urologic | Klumpen P.,Urologic | And 4 more authors.
World Journal of Urology | Year: 2015

Purpose: To evaluate the cost-effectiveness of robot-assisted partial nephrectomy (RAPN) and secondarily of laparoscopic PN (LPN) compared to the open procedure. Methods: Model-based cost-effectiveness analysis: The model was structured as decision tree. The model was populated with published data. We measured intraoperative, postoperative complications, and inhospital deaths. We expressed costs in US dollars ($).The reference analysis calculated the mean cost and the mean number of each endpoint over 5000 iterations using a second-order Monte Carlo simulation. We conducted extensive sensitivity analyses. Results: The mean inhospital costs were $13,186 for RAPN, $10,782 for LPN, and $12,539 for open partial nephrectomy (OPN), respectively. The incremental cost to prevent an inhospital event amounted to $5005 for RAPN compared to OPN. Lower RENAL scores were associated with lower incremental cost per avoided complications. Under assumption of 55 % higher costs in patients with complications, RAPN dominated OPN. LPN dominated OPN. We are aware of the following limitations: First, cost data for patients with and without complications were not available and we assumed the median cost for all cases, i.e., the analysis overestimated the cost associated with RAPN; second, we focused on inhospital estimates and did not apply a societal perspective. Conclusions: RAPN appears to be a cost-effective mean to avoid inhospital complications; however, these results might not apply to low-volume hospitals or to other health care systems. © 2015 Springer-Verlag Berlin Heidelberg

Lee R.K.,Cornell University | Mottrie A.,OLV Clinic | Mottrie A.,OLV Vattikuti Robotic Surgery Institute | Payne C.K.,Stanford University | Waltregny D.,University of Liege
European Urology | Year: 2014

Context Abdominal sacrocolpopexy (ASC) represents the superior treatment for apical pelvic organ prolapse (POP) but is associated with increased length of stay, analgesic requirement, and cost compared with transvaginal procedures. Laparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) may offer shorter postoperative recovery while maintaining equivalent rates of cure. Objective This review evaluates the literature on LSC and RSC for clinical outcomes and complications. Evidence acquisition A PubMed search of the available literature from 1966 to 2013 on LSC and RSC with a follow-up of at least 12 mo was performed. A total of 256 articles were screened, 69 articles selected, and outcomes from 26 presented. A review, not meta-analysis, was conducted due to the quality of the articles. Evidence synthesis LSC has become a mature technique with results from 11 patient series encompassing 1221 patients with a mean follow-up of 26 mo. Mean operative time was 124 min (range: 55-185) with a 3% (range: 0-11%) conversion rate. Objective cure was achieved in 91% of patients, with similar satisfaction rates (92%). Six patient series encompassing 363 patients treated with RSC with a mean follow-up of 28 mo have been reported. Mean operative time was 202 min (range: 161-288) with a 1% (range: 0-4%) conversion rate. Objective cure rate was 94%, with a 95% subjective success rate. Overall, early outcomes and complication rates for both LSC and RSC appeared comparable with open ASC. Conclusions LSC and RSC provide excellent short- to medium-term reconstructive outcomes for patients with POP. RSC is more expensive than LSC. Further studies are required to better understand the clinical performance of RSC versus LSC and confirm long-term efficacy. Patient summary Laparoscopic and robot-assisted sacrocolpopexy represent attractive minimally invasive alternatives to abdominal sacrocolpopexy. They may offer reduced patient morbidity but are associated with higher costs. © 2014 European Association of Urology.

Simone G.,Regina Elena Cancer Institute | Gill I.S.,University of Southern California | Mottrie A.,OLV Vattikuti Robotic Surgery Institute | Kutikov A.,Temple University | And 3 more authors.
European Urology | Year: 2015

Context On-clamp partial nephrectomy (PN) has been considered the standard approach to minimize intraoperative bleeding and thus achieve adequate control of tumor margins. The potential negative impact of ischemia on renal function (RF) led to the development of techniques to minimize or avoid renal ischemia, such as off-clamp PN and minimally ischemic PN techniques. Objective To review current evidence on the indications and techniques for and outcomes of minimally ischemic and off-clamp PN. Evidence acquisition A systematic review of English-language publications on PN without a main renal artery clamp from January 2005 to July 2014 was performed using the Medline, Embase, and Web of Science databases. Evidence synthesis The searches retrieved 52 papers. Off-clamp PN has been more commonly applied to small and peripheral renal tumors, while minimally ischemic PN is best suited for hilar and medially located renal tumors. These approaches are associated with increased intraoperative blood loss and perioperative transfusion rates compared to on-clamp PN. Minimally ischemic and off-clamp PN have potential functional benefits when longer ischemia time is anticipated, particularly for patients with lower baseline RF. Limitations include the lack of prospective randomized trials comparing minimally ischemic and off-clamp to on-clamp techniques, and the small sample size and short follow-up of most published series. The impact of different resection and renorrhaphy techniques on postoperative RF and its assessment via renal scintigraphy requires further investigations. Conclusions Minimally ischemic and off-clamp PN are established procedures that may be particularly applicable for patients with decreased baseline RF. However, these techniques are technically demanding, with potential for increased blood loss, and require considerable experience with PN surgery. The role of ischemia in patients with a contralateral healthy kidney and consequently an indication for elective minimally ischemic or off-clamp PN remains a debatable issue. Patient summary In this review we analyzed available evidence on minimally ischemic and off-clamp partial nephrectomy. These techniques, although technically demanding, may be particularly applicable for patients with decreased baseline renal function. © 2015 European Association of Urology.

Fisher R.A.,Kings College London | Dasgupta P.,Kings College London | Mottrie A.,Kings College London | Mottrie A.,OLV Vattikuti Robotic Surgery Institute | And 5 more authors.
International Journal of Surgery | Year: 2015

Introduction: Robotic surgery is a rapidly expanding field. Thus far training for robotic techniques has been unstructured and the requirements are variable across various regions. Several projects are currently underway to develop a robotic surgery curriculum and are in various stages of validation. We aimed to outline the structures of available curricula, their process of development, validation status and current utilization. Methods: We undertook a literature review of papers including the MeSH terms "Robotics" and "Education". When we had an overview of curricula in development, we searched recent conference abstracts to gain up to date information. Results: The main curricula are the FRS, the FSRS, the Canadian BSTC and the ERUS initiative. They are in various stages of validation and offer a mixture of theoretical and practical training, using both physical and simulated models. Discussion: Whilst the FSRS is based on tasks on the RoSS virtual reality simulator, FRS and BSTC are designed for use on simulators and the robot itself. The ERUS curricula benefits from a combination of dry lab, wet lab and virtual reality components, which may allow skills to be more transferable to the OR as tasks are completed in several formats. Finally, the ERUS curricula includes the OR modular training programme as table assistant and console surgeon. Conclusion: Curricula are a crucial step in global standardisation of training and certification of surgeons for robotic surgical procedures. Many curricula are in early stages of development and more work is needed in development and validation of these programmes before training can be standardised. © 2014 Surgical Associates Ltd.

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