Robotic Vessel Sealer Device for Lymphocele Prevention After Pelvic Lymphadenectomy: Results of a Randomized Trial

Pelvic Lymph Node Dissection With Polymer Ligation Clips Significantly Reduces Hospital Stay Compared to Vessel Sealer: A Retrospective Study

Introduction Lymphocele is a typical complication of pelvic lymph node dissection (PLND) in robot-assisted radical prostatectomy (RARP). This study aimed to compare postoperative lymphatic leakage between the polymer ligation clip and vessel sealer, and evaluated the costs associated with the former. Methods The study enrolled patients who underwent RARP with PLND at our institution between April 2018 and March 2023 and were treated with a vessel sealer (LigaSure Blunt Tip 44 NCTM; Medtronic, Dublin, Ireland) until September 2021, and Hem-o-lok polymer ligation clipsTM (Teleflex, Wayne, PA, USA) thereafter. The drain was removed on the third postoperative day or later, when the daily drainage volume was less than 200 mL. Results A total of 81 patients underwent RARP with PLND, which resulted in a significant increase in the operative (p = 0.016) and lymph node dissection times (p = 0.008) in the clip group. The total drainage volume (p = 0.048) was smaller, and the drain removal time (p = 0.039) and postoperative hospital stay (p < 0.001) were shorter in the clip group. Moreover, the device costs for the clips were lower than those for the vessel sealer. Conclusion Polymer ligation clips are associated with improved postoperative lymphatic leakage, shorter length of hospitalization, and lower costs, compared with vessel sealers.

Vascular Clips for Preventing Lymphocele and Symptomatic Lymphocele in Patients With Gynecologic Malignancies After Laparoscopic Pelvic Lymphadenectomy

STUDY OBJECTIVE

To evaluate the effectiveness of using vascular clips to seal targeted lymphatics in gynecological malignancies for the prevention of postoperative pelvic lymphocele and symptomatic lymphocele after laparoscopic pelvic lymphadenectomy.

DESIGN

Retrospective analysis.

SETTING

Single-center academic hospital.

PATIENTS

In total, 217 patients with gynecological malignancies were included.

INTERVENTIONS

Patients were classified into two groups: group 1 (vascular clips were used to seal the targeted lymphatics) and group 2 (electrothermal instruments were used to seal the targeted lymphatics). The patients were followed up 4-6 weeks after surgery to evaluate the incidence of lymphoceles by ultrasound or CT. Symptomatic lymphoceles are defined as those that cause infection, deep vein thrombosis with or without swelling of the extremities, edema (swelling) of the extremities or perineum, hydronephrosis, and/or moderate to severe pain.

MEASUREMENTS AND MAIN RESULTS

One hundred and thirteen patients were enrolled in group 1, and 104 patients were enrolled in group 2. Lymphoceles were observed in 46 (21.2%) patients. Fewer lymphoceles occurred in group 1 than in group 2 (8 [7.1%] vs. 38 [36.5%], p <.001). The percentage of significantly sized lymphoceles was lower in group 1 than that in group 2 (4 [3.5%] vs. 30 [28.8%], p <.001]. Symptomatic lymphoceles occurred in 18 patients (8.3%), and only one (1.0%) occurred in group 1, while 17 (16.3%) occurred in group 2 (p <.001). A multivariate analysis revealed that vascular clips were the only independent factor for preventing lymphocele (OR = 7.65, 95% CI = [3.30-17.13], p <.001) and symptomatic lymphocele (OR = 22.03, 95% CI = [2.84-170.63], p = .003).

CONCLUSION

The results indicate that the use of vascular clips may be useful for the prevention of the development of lymphocele and symptomatic lymphocele secondary to pelvic lymphadenectomy performed via laparoscopy.

The efficacy of peritoneal flap fixation on symptomatic lymphocele formation following robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection: a systematic review and meta-analysis

BACKGROUND

Pelvic lymphocele is the most common complication after robot-assisted radical prostatectomy (RARP) with pelvic lymph node dissection (PLND), of which symptomatic lymphocele (sLC) ranges up to 10% and is associated with poorer perioperative outcomes. Peritoneal flap fixation (PFF) is a promising intraoperative modification to reduce sLC formation but the clinical evidence failed to reach consistency.

MATERIALS AND METHODS

Randomized and nonrandomized comparative studies comparing postoperative sLC occurrence with or without PFF after RARP with PLND were identified through a systematic literature search via MEDLINE/PubMed, Embase, Web of Science, and CENTRAL up to July 2023. Outcome data of sLC occurrence (primary) and major perioperative events (secondary) were extracted. Mean difference and risk ratio with 95% CI were synthesized as appropriate for each outcome to determine the cumulative effect size.

RESULTS

Five RCTs and five observatory studies involving 3177 patients were finally included in the qualitative and quantitative analysis. PFF implementation significantly reduced the occurrence of sLC (RR 0.35, 95% CI: 0.24-0.50), and the specific lymphocele-related symptoms, without compromised perioperative outcomes including blood loss, operative time, and major nonlymphocele complications. The strength of the evidence was enhanced by the low risk of bias and low inter-study heterogeneity of the eligible RCTs.

CONCLUSION

PFF warrants routine implementation after RARP with PLND to prevent or reduce postoperative sLC formation.

The effect of the da Vinci® Vessel Sealer on robot-assisted laparoscopic prostatectomy complications

The da Vinci® Vessel Sealer is a major contributor to the total cost of robot-assisted laparoscopic prostatectomy (RALP). We aimed to assess whether the use of the Vessel Sealer is associated with better surgical outcomes in a population of patients that underwent RALP with lymphadenectomy. We tested whether the use of the Vessel Sealer is associated with the development of lymphocele and/or other surgical outcomes. Most surgeons used the Vessel Sealer in almost all or almost no patients. Thus, to avoid the potential confounding variable of surgeon skill, we performed the initial analyses using data from a single surgeon who changed practice over time, and then using the entire population. Overall, the Vessel Sealer was used in 500 (36%) RALPs. Surgeon 1 performed 492 surgeries, and used the Vessel Sealer in 191 (39%). The Vessel Sealer was not associated with better surgical outcomes in patients operated on by Surgeon 1. The odds ratio for development of lymphocele was 1.95 (95% confidence interval [CI] 0.57-6.75). In the entire population, use of the sealer was significantly associated with a very small reduction of blood loss (22 cc, CI 13-30) but with a 32-min increase in the operating room time (CI 26-37). Use of the Vessel Sealer will have, at best, a very small effect on RALP outcomes that is of highly questionable relevance given its cost. In light of these results, the Vessel Sealer will only be used at our institution in the context of clinical trials.

High BMI and Surgical Time Are Significant Predictors of Lymphocele after Robot-Assisted Radical Prostatectomy

Lymphoceles (LC) occur in up to 60% after robot-assisted radical prostatectomy (RARP) and pelvic lymphadenectomy (PLND). In 2-10%, they are symptomatic and may cause complications and require treatment. Data on risk factors for the formation of lymphoceles after RARP and PNLD remain sparse in the urologic literature and are inconclusive to date. The underlying data of this secondary analysis were obtained from the prospective multi-center RCT ProLy. We performed a multivariate analysis to focus on the potential risk factors that may influence lymphocele formation. Patients with LC had a statistically significant higher BMI (27.8 vs. 26.3 kg/m², p < 0.001; BMI ≥ 30 kg/m²: 31 vs. 17%, p = 0.002) and their surgical time was longer (180 vs. 160 min, p = 0.001) In multivariate analysis, the study group (control vs. peritoneal flap, p = 0.003), BMI (metric, p = 0.028), and surgical time (continuous, p = 0.007) were independent predictors. Patients with symptomatic lymphocele presented with higher BMI (29 vs. 26.6 kg/m², p = 0.007; BMI ≥ 30 kg/m²: 39 vs. 20%, p = 0.023) and experienced higher intraoperative blood loss (200 vs. 150 mL, p = 0.032). In multivariate analysis, BMI ≥ 30 kg/m² vs. < 30 kg/m² was an independent predictor for the formation of a symptomatic lymphocele (p = 0.02). High BMI and prolonged surgical time are general risk factors for the development of LC. Patients with a BMI ≥ 30 kg/m² had a higher risk for symptomatic lymphoceles.

Features and applications of energy devices for prone robot-assisted minimally invasive esophagectomy: a narrative review

BACKGROUND AND OBJECTIVE

Robot-assisted surgery is particularly useful in esophagectomy for esophageal cancer because robotic systems have high-resolution three-dimensional imaging, tremor filtering, and articulated instruments. This review article focuses on the applications and limitations of surgical devices in robot-assisted minimally invasive esophagectomy (RAMIE).

METHODS

A narrative search of Medline was performed for articles published using the keywords "robot-assisted esophagectomy", "technique", "postoperative complication", and "short-term outcomes".

KEY CONTENTS AND FINDINGS

Monopolar scissors: these devices with a sharp tip have an articulating function that allows for fast, sharp dissection without an electrical source. However, scissor-type devices cannot compress the organ, and their hemostatic ability is rather weak. Maryland bipolar forceps: the device has a very thin tip that allows for accurate dissection as well as stronger hemostatic ability by closing the forceps to compress tissues and applying electric current. The disadvantage is longer operation time because the forceps need to be constantly closed and reopened. Long Maryland bipolar grasper: the tip of the long Maryland bipolar grasper is slightly blunt and has the advantage of versatility because it can grip the tissue more delicately. Ultrasonic scalpel: the device can transect tissues speedily without bleeding, shortening operation time, but lacks articulating function. Although thermal spread to the surroundings is relatively narrow, activation time increases with the amount of tissue to be grasped; this raises the temperature above that of the vessel sealer. Vessel sealer: the device is one of the most powerful hemostatic energy devices, based on bipolar electrodes. The articulating jaws on both sides are more suited for sharp transection rather than meticulous dissection because of its powerful hemostatic force and blunt tip. It is also important to note that the vessel sealer produces widespread high-temperature steam. SynchroSeal: the device offers fast activation time, and due to the tip of the device being finely divided, which requires relatively precise manipulation.

CONCLUSIONS

Robot-assisted surgery reduces the limitations of conventional endoscopic surgery by offering stable high-resolution three-dimensional imaging, tremor filtering, and articulated instruments. It is important to understand and exploit the advantages of energy devices suitable for RAMIE.