Full robotic multivisceral resections: the Modena experience and literature review

Optimizing Urological Concurrent Robotic Multisite Surgery: Juxtaposing a Single-Center Experience and a Literature Review

Introduction: This article juxtaposes case series with a systematic review to evaluate the feasibility, safety, and clinical outcomes of concurrent robotic multisite urological surgeries, specifically robot-assisted radical prostatectomy (RARP) and robot-assisted partial nephrectomy (RAPN), for synchronous prostate and kidney cancers. Aim: The aims of this study were to evaluate the feasibility, safety, and clinical outcomes of urological concurrent robotic multisite surgeries through a comparison of institutional findings with the existing literature. Materials and Methods: A retrospective analysis was conducted on eight institutional cases of concurrent robotic multisite surgeries performed between 2021 and 2024. The primary outcomes measured were operative time, blood loss, and postoperative complications. A systematic review of the literature was performed, searching PubMed, Embase, and Cochrane Library databases, with the last search conducted on 1 July 2024. Studies were included if they reported on concurrent robotic surgeries corresponding to the procedures performed at the institution, including RARP with RAPN, RARP with robotic transabdominal preperitoneal inguinal hernia repair (RTAPPIHR), and other multisite robotic surgeries. Risk of bias was assessed using the modified Newcastle-Ottawa Scale. Descriptive statistics were used to analyze operative time and blood loss, with confidence intervals (CIs) calculated to assess precision. Categorical variables, including postoperative complications, were summarized using frequencies and percentages. Heterogeneity was assessed using the I2 statistic, with values above 50% indicating substantial heterogeneity. A random effects model was applied when necessary, and sensitivity analyses excluded studies with high risk of bias. Results: We describe a unique docking technique employed in our procedures, which allows for atraumatic transitions between surgeries using the same port sites. Our institutional cases demonstrated the feasibility and safety of concurrent robotic multisite surgery, with a mean operative time of 315 min (95% CI: 290-340) and mean blood loss of 300 mL (95% CI: 250-350). There were no significant intraoperative complications reported. These findings are consistent with the literature, where mean operative times range from 390 to 430 min and blood loss ranges from 200 to 330 mL. Notably, no positive surgical margins or declines in postoperative renal function were observed in our cases. The systematic review included nine retrospective studies involving 40 cases of concurrent RARP and RAPN, as well as eleven studies including 392 cases of RARP combined with RTAPPIHR. The findings from these studies support the feasibility and safety of concurrent surgeries, showing similar rates of operative time, blood loss, and postoperative complications. Conclusions: Concurrent robotic multisite surgeries, such as RARP combined with RAPN or RTAPPIHR, appear to be safe and feasible. Our data suggest these procedures are non-inferior to separate surgeries in terms of safety and complication rates. Potential benefits, including reduced operative times, shorter hospital stays, and more efficient resource use, may translate into cost savings, although no formal cost-effectiveness analysis was conducted. Limitations include the small sample size, retrospective design, and lack of long-term follow-up. Prospective trials are needed to validate these findings and further refine the techniques. Funding: this review did not receive any external funding. Registration: this review was not registered in any public protocol registry due to its comparative retrospective nature.

Experience with Laparoscopic and Robotic Colon Surgery Together with Other Major Minimally Invasive Procedures for Unrelated Pathologies

Background: Indications for combined colon surgery together with other procedures include oncologic multivisceral resections and abdominal trauma. It is unclear if combining minimally invasive (MI) colon surgery with unrelated other procedures increases the risk for complications. Patients and Methods: The surgical database from two institutions during a 10-year period was queried for combined colon surgeries together with other interventions. All open cases, combined cases performed for one pathology and MI colectomies together with a minor procedure, were excluded. Results: Median age of the 6 men and 7 women was 64.4 (range 42.7-75.4) years. Colon surgeries included right (5), sigmoid (4) transverse (1) colectomies, rectum resection (1), rectopexy (1), and colostomy reversal (1) with indications of colorectal cancer (5), diverticulitis (3), benign ileocecal mass (1), colonic volvulus (3) and rectal prolapse (1). Second procedures included two splenectomies (sarcoidosis, ITP), paraesophageal hernia repairs (4), right diaphragmatic repairs [eventration (2) and Morgagni type hernia]; cholecystectomies (2), appendectomy (acute appendicitis), duodenal wedge resection (carcinoid), reversal of a gastric bypass (Roux limb stricture) one each. Cases were done laparoscopically (7) and robotic assisted (6). In most cases only 4 trocars were used. Median OR time was 4.3 (range 2.5 to 6.6) hours. No anastomotic breakdown was observed. Conclusions: Combining MI colectomy and other major abdominal surgeries can be safely done and in this series did not increase morbidity or mortality but avoids a second operation. Patient selection seems important and port placement may need to be altered to achieve good exposure for both procedures.

Robotic assisted laparoscopy for deep infiltrating endometriosis

Deep infiltrative endometriosis is a condition affecting up to 15 % of women of childbearing age, defined by extra uterine location of endometrial like tissues. The symptoms of endometriosis range from severe dysmenorrhea to infertility, chronic pelvic pain, bowel dysfunction and urinary tract involvement to name the most common. Endometriosis has an impact on the quality of life of patients, with personal and social consequences. Although medical treatment is indicated in the first instance, surgery may be necessary. Standard laparoscopy has become the gold standard for this surgery. However, surgery for deep infiltrative endometriosis is known to be highly complex, and the significant development of robotic assistance in recent years has had an impact on the evolution of surgical practice. This comprehensive review of the literature provides an overview of the contributions of robotic surgery in the field of endometriosis and gives an insight into the next steps in its development.

Feasibility of robotic multivisceral resections in colorectal cancer patients: a NSQIP-based study

Multivisceral robotic surgery may be an alternative to sequential procedures in select patients with colorectal cancer who are diagnosed with synchronous lesions or in those who require additional procedures at the time of resection. The aim of this study was to assess utilization of the robot for multivisceral resections and compare the surgical outcomes of this approach to laparoscopic resections. Adult colorectal surgery patients who underwent a colectomy or proctectomy and a concurrent abdominal surgery procedure in the American College of Surgeons NSQIP database (2016-2021) were included. The primary outcomes were 30-day postoperative overall and serious morbidity. Factors associated with morbidity were assessed using a multivariable logistic regression. Of the 3875 patients who underwent simultaneous multivisceral resections, 397 (10.3%) underwent a robotic approach and 962 (24.8%) a laparoscopic approach. Gynecological procedures (38%) comprised the largest proportion of concurrent procedures followed by hepatic resections (18%). On unadjusted analysis, rates of overall morbidity (25.4% vs. 30.0%) and serious morbidity (12.1% vs 12.0%) did not differ between the robotic and laparoscopic approach groups, respectively. The rate of conversion to open was lower for the robotic compared to laparoscopic approach (9.3% vs. 28.8%, p < 0.001), and length of stay was shorter (4 vs. 5, p < 0.001). On adjusted analysis, there was no significant difference in overall (OR 0.87, 95% CI 0.65-1.16, p = 0.34) or serious morbidity (OR 1.12, 95% CI 0.75-1.65, p = 0.59) between the two approaches even after concurrent procedure risk stratification. Robotic multivisceral resections can be performed with acceptable overall and serious morbidity in select patients with colorectal cancer. Rates of conversion and length of stay may be decreased with a robotic approach, and future research is needed to determine the optimal operative approach in this patient population.

Imaging of Ganglioneuroma: A Literature Review and a Rare Case of Cystic Presentation in an Adolescent Girl

Retroperitoneal ganglioneuroma is a rare neuroectodermal tumor with a benign nature. We performed a literature review among 338 studies. We included 9 studies, whose patients underwent CT and/or MRI to characterize a retroperitoneal mass, which was confirmed to be a ganglioneuroma by histologic exam. The most common features of ganglioneuroma are considered to be a solid nature, oval/lobulated shape, and regular margins. The ganglioneuroma shows a progressive late enhancement on CT. On MRI it appears as a hypointense mass in T1W images and with a heterogeneous high-intensity in T2W. The MRI-"whorled sign" is described in the reviewed studies in about 80% of patients. The MRI characterization of a primitive retroperitoneal cystic mass should not exclude a cystic evolution from solid masses, and in the case of paravertebral location, the differential diagnosis algorithm should include the hypothesis of ganglioneuroma. In our case, the MRI features could have oriented towards a neurogenic nature, however, the predominantly cystic-fluid aspect and the considerable longitudinal non-invasive extension between retroperitoneal structures, misled us to a lymphatic malformation. In the literature, it is reported that the cystic presentation can be due to a degeneration of a well-known solid form while maintaining a benign character: the distinguishing malignity character is the revelation of immature cells on histological examination.

Concomitant robot-assisted laparoscopic surgeries for upper and lower urinary tract malignancies: a comprehensive literature review

Worldwide, we have witnessed an expansion of robot-assisted laparoscopic surgery (RALS) and thanks to the global adoption of high-resolution diagnostic imaging technologies, an increased incidence of newly diagnosed prostatic, renal and bladder cancers has been recorded with concurrent second primary urological cancer diagnoses increasing by 1.5%. Diverse authors have reported their findings concerning synchronous multi-visceral malignances robotic treatment within the scientific literature. The aim of this study is to comprehensively review all reported articles describing concurrent upper and lower RALS using a singular robotic port scheme within the same intervention for renal malignances and concomitant prostatic or bladder cancers. To the best of our knowledge and vigorous literature search, this is the first study that comprehensively evaluates and reports all combined upper and lower urinary tract surgeries published so far. In carefully selected patients, thanks to multidisciplinary preoperative assessment and surgical planning a combined robotic approach can reduce the morbidity, complications, hospital admissions and the overall length of hospitalization.