Urology

Robotic Urological Operations

Urology is among the medical fields with the highest rate of technological advancements, including the use of robotic surgery. The da Vinci system is the robotic platform that has taken minimal invasive surgery one step further making advanced delicate procedures possible with ease.

Prostate cancer

The prostate is a walnut-sized gland in men, located just below the bladder and in front of the rectum, surrounding the urethra (the tube through which urine is transferred out of the bladder). Its main function is to produce and store (in the seminal vesicles) fluid that contributes to make semen. Prostate cancer is characterized by uncontrolled (malignant) growth of prostatic cells in the gland and is the second-leading cause of cancer death in men, following lung cancer.

Robotic radical prostatectomy for the treatment of prostate cancer has been for many years the most often robotic surgery performed worldwide. During the procedure, the surgeon removes the whole prostate gland relieving the patient from cancer while meticulously dissecting around the surrounding structures and nerves, thus offering a high probability of continence (urinary control) and potency (preserving sexual function). Robot assisted radical prostatectomy is a minimal invasive procedure and is performed through five to six keyhole incisions, which offers the advantages of reduced blood loss, reduced pain, shorter hospital stay and a significantly faster recovery than open surgery.

Renal Cancer

Robotic Radical Nephrectomy: is a minimally invasive surgical option that provides greater precision and accuracy than traditional open kidney surgery. Among others it offers less blood loss, fewer complications, faster return of bowel function after surgery, reduced risk of complications, less pain and pain medication, faster return to normal activities, shorter hospital stay and smaller incisions.

Robotic Partial Nephrectomy: One of the greatest advancement in surgical urology is the possibility to remove only the tumor form the kidney, preserving in this way the rest of the functional organ. The implications for the patient are many including avoiding renal insufficiency and renal failure. Once again, the robotic platform offers the surgeon the ability to safely proceed with this highly advanced procedure with all the above-mentioned advantages for the patient.   

Bladder cancer

Bladder cancer can be cured when diagnosed and treated early. Treatment depends on many factors: including the grade of cancer, whether the cancer is confined to the mucosa of the bladder (superficial) or has invaded the muscular layers of the bladder (invasive), as well as the patient's health status and lifestyle needs. Surgery is the mainstay for bladder cancer. The type of operation performed depends on the invasiveness of the cancer at diagnosis. 

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    Athens Medical Center

    Dr. George Kyriakou, MD, PhD, FEBU

    Director of Minimally Invasive Urology Center

    • Faculty member of IRCAD / EITS, a Division of Medicine at the University of Strasbourg
    • 1st price for the best presentation Int. meeting in stone disease, Dubai, 2012

    Dr. Nikolaos P. Pardalidis, MD, PhD, FEBU

    • Fellowship: Endourology and Laparoscopic Surgery in Long Island Jewish Medical Center, New York
    • 123 publications in Greek and International Journals
    • More than 250 citations in international journals and textbooks

    Dr. A. Ploumidis, MD, PhD, FEBU, FHCS

    Director of Center for Robotics & Laparoendoscopic Surgical Urology-Andrology

    • Vice president of the Greek Scientific Society of Robotic Surgery (G.S.S.R.S.)
    • Fellow of the European Board of Urology

    Dr. Achilles Ploumidis, MD, BSc, MSc, PhD, FEBU

    Surgeon Urologist-Andrologist

    • Fellow of the European Board of Urology (FEBU)
    • European Urological Scholarship Programme (EUSP)
    • First Prize for Best poster presentation - Junior European Robotic Urologic Symposium (ERUS) 2011

    European Interbalkan Medical Center

    Dr. Andreas Andreou

    Urologist

    • Dr. of Hôpital Universitaire de Rouen and Hôpital Foch – Paris V
    • First robotic inguinal lymphadenectomy in Europe

    Dr. Athanasios Bekos

    Urologist

    • First robotic inguinal lymphadenectomy in Europe
    • Member of European Board of Urology
    • Member of South-Eastern Europe Robotic Surgery Society (SEERSS)
    MORE

    Dr. Apostolos Labanaris

    Urologist

    Related Articles

    05.07.16
    Prostate Cancer: The role of robotic-assisted surgery

    Writen by Apostle Lampanaris,MD, PhD Urologist-Surgeon, Certified in Robotic Surgery at the Medical Balkan Thessaloniki

    And George Lampanaris, MD, PhD  Urologist-Surgeon, Certified in Robotic Surgery at the Inter-balkan Medical Centre of Thessaloniki

    Today, in almost all developed Western societies, prostate cancer is the most common malignant disease in men and the second leading cause of death from cancer in men, after lung cancer.

    More commonly it occurs in people over 60 years old. Annually, in Greece approximately 4,500 men are suffering from prostate cancer; however, early diagnosis increases greatly the chances of complete cure.

    Prostate - prostate cancer diagnosis - treatment

    Prostate is a gland of the male reproductive system. It has the shape and size of a chestnut.

    It is located behind the pubic symphysis, just below the urinary bladder and surrounds the initial part of the urethra. Its function is related to fertility.

    Prostate specific antigen (PSA), is a special protein produced in the prostate gland, and it is essential for the sperm liquefaction. When the gland’s architecture is disturbed (such as cancer), small amounts escape into the circulation and can be measured in the blood. Small or moderate increases often accompany benign conditions, too, such as benign prostatic hyperplasia or prostatitis. Thus, PSA increase does not always mean that the man has prostate cancer, but he should certainly consult a urologist.

    Normally, there is an ongoing renewal process of the body’s old cells with new ones. Cancer is nothing more than a disturbance of this normal process, resulting in the production of more new cells, without completing old cells’ life cycle. Malignant tumours arising in the prostate, due to this irregular cell reproduction, constitute prostate cancer, and the main feature of cancer cells is that they can metastasise to other organs.

    At an early state, prostate cancer may not cause any symptoms, making its course even more insidious. As the disease progresses and the tumour size increases, it may push the urethra and prevent urine flow during urination.

    What does treatment include?

    1. Careful monitoring and awaiting.
    2. External radiation and brachytherapy.
    3. Radical prostatectomy (open - laparoscopic - robotic)

    What is robotic-assisted surgery?

    By “robotic assisted surgery”, we mean the use of robotic systems in surgical practice, aiming at facilitating and perfecting the surgical operation for the benefit of the surgeon and the patient. “Robotic surgery” as it is simply called, is a development of laparoscopic and endoscopic surgery. It is actually a laparoscopic surgery, performed with the assistance of a robot.

    I.e. it is a minimally traumatic and invasive surgical method, during which surgical operations are performed with great accuracy, with the aid of very thin and flexible instruments, which are inserted inside the patient's body through tiny holes in the skin, thus avoiding large incisions and painful. The term robot should not be confused: the surgeon performs the surgery through the use of a robot, which is fully controlled by the surgeon.

    Robot-assisted radical prostatectomy

    Radical prostatectomy is the complete removal of the prostate, together with its capsule and surrounding tissues, including the seminal vesicles. Pelvic lymphadenectomy is performed depending on the stage and degree of aggressiveness in specific cases. Robot-assisted radical prostatectomy is performed through a minimally traumatic surgery. Oncological outcomes, published worldwide for robotic prostatectomy, show excellent cancer control, with faster return of urinary continence and sexual function.

    Advantages

    Due to both the three-dimensional and magnified vision and the accuracy and freedom of motion, which allow us to perform the surgery as if the surgeon's hands were inside the patient's body, the possibilities of urinary continence and erectile function preservation are significantly greater, as compared to those after simple laparoscopic or open surgery.

    It provides better opportunity for radical removal of the prostate and nearby lymph nodes, where required, resulting in fewer relapse problems and longer survival, without signs of cell disease, which constitute prostate cancer and may metastasise to other organs.

    19.04.16
    Athens Medical Centre: The first operation of robotic radical prostatectomy with the neurosafe technique in Greece

    Athens, April 19, 2016 - The pioneering NeuroSAFE technique was performed for the first time in Greece in radical prostatectomy robotic surgery, by the Surgeon – Urologist Dr. Stavros I. Tyritzis, at the Minimally Invasive Urologic Surgery Department of the Athens Medical Centre. Robotic radical prostatectomy with the “NeuroSAFE” technique was conducted with the ultramodern da Vinci Si HD device, in a 50 year old patient with aggressive extraprostatic disease, with excellent oncological and functional outcomes.

    Robotic radical prostatectomy using the DaVinci SI system, available at Athens Medical Centre, is the golden treatment option for the management of localised and locally advanced prostate cancer. Its superiority lies in the better maintenance of erection, urinary continence, reduction to elimination of postoperative complications and, of course, in the oncological outcome.

    In this context and according to the European guidelines, the surgeon, with the robotic system’s aid is now able to proceed with aggressive preservation of the neurovascular bundle, ensuring the complete disappearance of the disease.  In the past this was not possible in patients with extensive or aggressive disease, and the surgeon was obliged not to proceed to neuroprotective radical prostatectomy, sacrificing the nerves and blood vessels of erection and continence, which are in direct contact with the prostate.

    Furthermore, the innovative NeuroSAFE technique allows the “introduction” of the microscope in surgery, so that the surgeon can decide before the completion of the operation if nerves should be preserved, as they may have been affected by the disease at the microscopic level. The surgeon removes the prostate through a specially shaped hole, with no need to remove the robot system from the patient. Then, in collaboration with the pathologist, he examines the prostate regions where bundle of erection has been detached and fully preserved, so that to ensure the ideal oncological outcome.

    “With NeuroSAFE technique, firstly performed by us at Athens Medical Centre, we managed to raise the level of the offered surgical service, with great benefits for patients, who will probably avoid radiation and hormonal therapy after surgery,” said Dr. Stavros I. Tyritzis, Surgeon - Urologist, Centre for Minimally Invasive Urologic Surgery, Athens Medical Centre, Assistant Professor of Oncology and Urogenital Robotics, Karolinska University Sweden and Doctor of Medicine of the University of Athens.

    The Centre for Minimally Invasive Urologic Surgery of the Athens Medical Centre, with Director Dr. George Kyriakou, has a specialised multidisciplinary team of Surgeons-Urologists, Radiologists, Pathologists, Oncologists and Radiotherapists (MultiDisciplinary Team) for the comprehensive treatment of urological cases, through the most modern methods. As part of research protocols, the Centre cooperates with the world's leading cancer centre MD Anderson Cancer Centre.

    05.01.16
    Robotic Radical Prostatectomy

    The operation that combines the accuracy of a robot with the surgeon’s medical judgment

    Written by Achilles Ploumidis, MD, BSc, MSc, PhD, FEBU, Surgeon Urologist - Urogynacologist, Centre of Robotic & Laparoscopic Surgical Urology - Andrology in Athens Medical Centre

    Prostate cancer is the most common type of cancer among Europe’s elderly men, as well as the second cause of death from neoplasia after lung cancer. It is characterised by great heterogeneity both in terms of occurence and progress. More specifically, it may have an asymptomatic course, especially in the early stages, while other times the patient has clinical symptoms, with obstructive or irritative symptoms during urination. Furthermore, haematospermia or perineal pain may also occur frequently.

    However, early diagnosis, and thus treatment of the disease is possible. Prevention plays a primary role. Thus, men over 50, or over 45 years in case of family history of prostate cancer, should undergo a special blood test (PSA - prostate specific antigen) and the necessary clinical assessment by their urologist.

    Radical prostatectomy is an effective treatment for localised prostate cancer, among others. This operation involves total removal of the prostate and seminal vesicles with simultaneous bilateral pelvic lymph node cleaning according to the indications.

    In 2006 the first robotic system in Greece was installed at Athens Medical Centre. Following the European and American standards, since then more and more robotic-assisted surgical operations are performed, both for malignant and for benign urinary tract diseases.

    Robotic radical prostatectomy is a minimally invasive surgical method, in which all surgical operations are performed with the aid of a robot, which is controlled by the surgeon through a special console. Special handles on the console allow the transmission of the surgeon’s moves to the robot’s arms with much greater flexibility and stability than that of the human wrist. The tiny tools that are adjusted to the surgical arms, and the high-definition magnified and three-dimensional imaging of the organs of the human body allow difficult surgical manipulations with expertise and precision. During surgery, 5 small holes are created (less than 1 cm) at the lower abdomen, from which miniature instruments are inserted. Prostate removal is performed bloodlessly and with absolute optical precision, while maintaining the integrity of neurovascular bundles and creating a water-tight vesicoureteral anastomosis that will ensure good erectile function and continence postoperatively.

    Benefits of Robotic Prostatectomy

    • Less blood loss - lower chance of transfusion
    • Direct urinary continence
    • Better erectile function
    • Faster recovery and quicker mobilisation of patients
    • Faster return to daily- professional activities
    • Shorter hospitalisation and therefore quicker exit from hospital
    • Better aesthetic result
    • Quick catheter removal
    • Minimisation of postoperative pain, less use of analgesics and fewer postoperative complications.

    17.11.15
    Athens Medical Centre: Robotic treatment of genital prolapse

    Athens, November 17, 2015 - The Urologic Department of the Athens Medical Centre performs with great success the specialised laparoscopic and robotic method with the “daVinci” system for the treatment of genital prolapse in women. To date, more than 120 cases have been successfully treated at Athens Medical Centre - a figure that is a milestone for minimally invasive urology.

    This is a particularly successful technique, combining open surgery’s effectiveness with the benefits of a minimally invasive method. It repairs all 3 types of prolapse (cystocele, uterine prolapse, rectocele), achieving the positioning of multiple sutures to support the mesh through the fully coordinated, accurate and stable movements of the robotic arm.

    The procedure is short, as only 1- 2 days of hospitalisation are required, while the advantages include mimimal blood loss, limited postoperative pain, minimal recurrences with better preservation of the outcome over time as compared to other techniques from the sinus, zero rates of mesh infection and rejection, and preservation of good and healthy sex life.

    “Over 50% of women who have had children show some degree of prolapse. Indeed, more than 200,000 prolapse operations are performed annually, while the possibility of prolapse and incontinence to occur in a woman-mother in her life reaches 11.1%.  The extensive experience of the urology team of Athens Medical Centre during the past 8 years makes it one of the leading ones in Europe, while it has benn officially recognised by the European Association of Urology”, stated the Director of Minimally Invasive Urologic Surgery Department of the Athens Medical Centre, Mr. George Kyriakou.

    23.09.15
    Athens Medical Centre: Urologic robotic surgeries in patients who have lost part or all of the lung

    Athens, September 23, 2015 - During the past six months, a significant number of robotic radical prostatectomies and robotic partial nephrectomy robotic surgical operations were performed successfully at Athens Medical Centre, in patients who had lost part or all of their lung due to cancer. It is worth noting that such surgeries are rare in Europe, since integrity, scientific training and coordination of a team of doctors of various specialties is required. 

    Patients recovered very quickly without complications, and they were discharged from the hospital just 2-3 days after surgery.

    In recent years, there has been significant progress in prostate cancer and tumour-like kidney lesions surgeries. Now, thanks to the daVinci robotic system, available at Athens Medical Centre, the results recorded both in oncology and in operational parameters (urinary continence and preservation of erectile function) of radical prostatectomy are excellent. The same surgical method has contributed extremely in the surgical treatment of kidney tumours, through their selective ablation instead of the whole kidney (partial nephrectomy). Furthermore, a great number of good results have been recorded in the eradication of up to 7 cm long tumours, while the function of the remaining kidney is very good, with the lowest possible ischaemic renal stress.

    Dr. George Kyriakou, Director of the Centre of Minimally Invasive Urology at Athens Medical Centre, stated: “In Europe, prostate cancer is the most common type of tumor and 2nd most common cause of death due to cancer in the male population, while renal cell cancer is the most common renal epithelial malignant neoplasia, and it is responsible for over 90% of all renal malignancies. Nevertheless, at European level, robotic surgeries are rare in patients who have already lost part or all of their lung due to cancer.  We are proud at Athens Medical Centre, since we have succeeded in making these successful operations, actively demonstrating our commitment to continuous leadership.”

    It is worth noting that the robotic surgery constitutes a minimally invasive surgical operation without incisions, with no or minimal postoperative pain, faster recovery and return to everyday life for the patient. Due to the fact that no incision exists on the abdominal walls and minimum trauma, metabolic stress is lower than an open surgery. 

    23.07.15
    Robotic Urogynacological Surgery: The permanent treatment of pelvic floor prolapse while the uterus is preserved

    Written by Written by Achilles Ploumidis, MD, BSc, MSc, PhD, FEBU, Surgeon Urologist - Urogynaecologist, Centre of Robotic & Laparoscopic Surgical Urology - Andrology in Athens Medical Centre

    What is pelvic floor prolapse?

    This is the projection of one or more organs of lesser pelvis through the vagina, which end up extending beyond the labia. These organs may be: the uterus, the vaginal cuff (in case of preceding hysterectomy), the bladder, the intestine strands, or even the rectum. This prolapse occurs during intra-abdominal pressure increase (sneezing, coughing, weight lifting), and it is due to the relaxation of ligaments, fascias and the peritoneal muscle wall, all of which form a complex network of dynamic and static support of the pelvic organs.

    What are the symptoms of pelvic floor prolapse?

    • Permanent feeling of heaviness in the perineum or vagina, which is often also transfered to the lumb (waist).
    • Displacement (descent) of the uterus or a soft organ in various movements, which can project outside the vagina.
    • Lower urinary tract symptoms, such as: weak urination, difficulty in urination, feeling of obstruction during urination, feeling of incomplete bladder emptying, frequent urination, urgency, urinary incontinence.
    • Gastrointestinal system symptoms, such as constipation, feeling of incomplete emptying during defecation.
    • Discomfort during sexual intercourse.
    A. Normal anatomy of the female pelvis. II. Various types of pelvic floor prolapse: prolapse of the anterior compartment (cystocele), prolapse of the central compartment (uterine prolapse) and prolapse of the posterior compartment (rectocele). III. The correction of pelvic floor prolapse is achieved robotically through the suspension of the vagina to the sacrum

    How common is pelvic floor prolapse?

    Pelvic floor prolapse is one of the most common urogynaecological problems that adult women face. The impact increases with age and, in fact, one in three women over 50 will seek medical attention due to the symptoms. Unfortunately, many women are overwhelmed by shame, reduced sexuality and as a result, self-esteem, leading to the disease often remaining in a latent state, with serious impact on quality of life.

    Types of pelvic floor prolapse:

    When prolapse occurs in the anterior wall of the vagina, then it is called anterior compartment prolapse. Since the organs projecting from the anterior compartment are the bladder and/ or urethra, it is often called cystocele or urethrocystocele, respectively. This type of prolapse is the most common and affects, in most cases, urination function (obstructive symptoms). Correspondingly, when the prolapse concerns the posterior wall of the vagina, then it is called prolapse of the posterior compartment. In this case, the organ projecting is the rectum, which is why the prolapse is called rectocele.

    However, part of the small intestine may be also projecting from the upper part of the posterior vaginal wall, known as enterocele. Finally, when the uterus or vaginal cuff projects (in case of hysterectomy), it is a prolapse of the central compartment. Uterus or vaginal cuff prolapse is the second most common type of pelvic floor prolapse. It should be emphasised that the separation of the condition into three compartments (anterior, central and posterior) is of particular diagnostic and therapeutic importance, although a woman may have a combination of the above: i.e. she may have a cystocele with vaginal cuff prolapse, especially following hysterectomy surgery. For this reason, the condition should be treated as a single disease.

    The causes of pelvic floor prolapse:

    Pelvic floor prolapse is mainly due to the relaxation of muscles, ligaments and fascias supporting the pelvic organs. This, in turn, is caused by the following conditions:

    • Pregnancy and childbirth are considered among the most important factors. In fact, one in three women who have given birth will ultimately suffer from the disease, which may even occur some years after pregnancy. However, it is important to note that only 1 in 9 women will need surgery.
    • Increased age and menopause are among the factors that cause pelvic floor ligaments relaxation.
    • Most of the times chronic increase of intra-abdominal pressure is released on the pelvic floor, resulting eventually in its downwards displacement. Conditions that increase intra-abdominal pressure include: obesity, chronic cough, constipation and weight lifting.
    • There are women who are prone to pelvic floor prolapse, while there are also some connective tissue disorders, which affect ligaments’ strength.

    Treatment of pelvic floor prolapse:

    Pelvic floor prolapse is not a life-threatening condition, while some women actually have minimal symptoms, and their daily lives are not affected. Therefore, depending on the degree of prolapse, the woman's age and the symptoms, the physician can recommend the corresponding treatment. Treatments are mainly divided into conservative (non-surgical) and surgical.

    Conservative Treatments:

    • Behavioural change: Body weight reduction (in case of overweight women), avoiding weight lifting and avoiding any cause of intra-abdominal pressure increase, such as chronic constipation and chronic cough (frequent in smokers).
    • Transvaginal pessary placement: The pessary is a device (usually silicon) placed by the physician into the vagina, with the aim to mechanically support the prolapsing organs. Therefore, the woman feels released of the symptoms to some extent, while the main advantage is the avoidance of surgery. It is not recommended for young women as it complicates intercourse and frequent changes are needed.
    • Exercises for the strengthening of the pelvic floor (Kegel exercises): Since perineal muscle relaxation is one of the factors of pelvic floor prolapse, strengthening these muscles through appropriate exercises, which will be recommended by the physician, can improve symptoms and prevent further relaxation at that area. These are the first treatments to be applied, especially in cases of small prolapse.

    Surgical Treatments:

    With robotic surgery, the large incisions of classic open surgery are replaced by 4 small openings on the abdominal wall.

    Surgical treatment is recommended in cases where conservative measures have failed, to young women as well as in moderate and high degree of prolapse. There are several techniques applied, and they are classified mainly as: transvaginal procedures (through the vagina) and transabdominal procedures (through the abdomen). Surgical repair may be performed with or without the use of a mesh. It is important to note that, according to international literature, the use of a mesh provides a permanent solution to the problem with lower chances of relapse. Current concerns over the use of the mesh relate mainly to its use in transvaginal (through the vagina) repair operations. As is known, the vagina has a normal microbial flora, which may subsequently contaminate the mesh. The operations performed transabdominally are free from such risks, since the abdominal cavity has bacteria. Besides, transabdominal use of a mesh is the gold standard in other general surgical operations with similar aetiolopathology, such as restoring hernias of the abdominal wall and the inguinal region.

    Robotic Sacrocolpopexy & Robotic Hysteropexy:

    Sacrocolpopexy is an operation aiming at restoring normal anatomical position and function of the vagina (in women who have undergone hysterectomy), and in preventing pelvic organs descent. This is achieved with the placement of a mesh in the anterior wall of the vagina, i.e. between the vagina and bladder (thus repairing any cystocele), as well as in the posterior wall of the vagina, i.e. between the vagina and rectum (thus repairing any rectocele and enterocele). These two meshes are placed on the sacrum, thus providing strong support to the vaginal cuff (and thus repairing vaginal prolapse). It is proven (CochraneReview) that the above procedure has the fewer relapses. However, the disadvantage of the above operation (so far) in relation to transvaginal operations, is that it requires open abdominal incision and it is more time consuming. Today, however, with the application of robotic surgery, which is the method of choice for pelvic operations in particular, the above procedure (robotic sacrocolpopexy) can be performed in a minimally invasive manner. This way, low recurrence rate of a transabdominal surgery are combined with minimal complications and inconvenience of a transvaginal operation.

    With the robotic platform the surgeon’s moves are transferred to the robotic instruments to a scale (Downscaling), providing accuracy in tissue preparation

    Furthermore, with robotic surgery women can undergo uterus and cystocele proptosis repair operation, while their uterus is preserved with minimally invasive manner (robotic hysteropexy).

    The long-held view that in cases of uterus prolapse the uterus should be removed has been revised, and today it has been proven that uterus drop is the result and not the cause of the disease.

    30.06.15
    The First Single Site Robotic Pyeloplasty in Southeastern Europe was performed at Athens Medical Centre

    Athens, July 30, 2015 - The first single site robotic urological surgery in Southeast Europe was performed successfully at Athens Medical Centre by Surgeon Urologist - Andrologist, Dr. Achilles Ploumidis. Single site robotic pyeloplasty was recently performed with the modern da Vinci Si HD system, in a young patient with chronic kidney obstruction, where the constriction of the renal pelvis was repaired with ipsilateral ureter, preserving good renal function.

    The operation was performed entirely by a single 2 cm incision through the umbilicus and the patient was discharged from hospital in less than 24 hours, with minimal postoperative pain.

    Modern surgery is no longer performed with large incisions, as in the past. In robotic surgery, the actual three-dimensional vision, articulated instruments, as well as the ergonomic console give a significant advantage to the surgeon in terms of tissue preparation and accuracy during surgery. In addition, robotic surgery can be performed by a 2 cm incision through the umbilicus, achieving minimal blood loss, less postoperative pain and faster recovery, while at the same time the cosmetic result is excellent and they leave abdominal wall intact.

    “Athens Medical Centre has pioneered internationally, since from 2011 single site robotic surgeries are systematically performed safely and successfully in general and gynaecological surgical operations. Now, recent technological advantages in robotic instruments construction and in the overall single site robotic platform allow the use of this technology in urology operations of the kidney. It is worth noting that single site robotic surgery is a rapid advancement and it is expected to be applied to further urology operations” said Dr. Achilles Ploumidis.

    The urology clinic of Athens Medical Centre, with Director Dr. Anthony Ploumidis, has now extensive experience in robotic surgeries, which were initiated in 2006 when the first in Greece da Vinci robotic system was installed. Today, a large number of oncological surgeries for prostate, kidney and bladder, as well as urinary system repair surgeries, and urogynaecological operations have been performed successfully. Moreover, the role of urology clinic’s executive members is also important (Director: A. Ploumidis) in training young European urologists, in writing articles for recognised scientific journals and in lectures in European conferences. 

    04.04.15
    Genital Prolapse: Causes, Symptoms, Treatment

    Written by Dr. George Kyriakou, Urologist, Faculty Member, IRCAD/EITS, Strasbourg, Director of Minimally Invasive Urology Department,  Athens Medical Center, Athens Medical Group

    Some medical problems of women, such as urinary incontinence and genital prolapse, are still a taboo in 2015, causing social isolation.

    A passive attitude towards prolapse and incontinence is considered absolutely wrong, since that woman's pathology is now treated by urology with excellent room for improvement and rehabilitation.

    Pelvic organ prolapse is the descent of urogenital organs in the pelvis of the woman, due to vaginal wall degeneration and collagen damage. It may relate to a hernia of any combination, such as bladder (cystocele)cervix, or intestine and rectum (rectocele).

    Over 50% of women who have had children show some degree of genital prolapse. Many are asymptomatic, and thus they do not want or require treatment. 38% of women with genital prolapse mention annoying symptoms and 25% of them has problems in quality of life. More than 200,000 prolapse operations are performed annually, while the possibility of prolapse and incontinence for a woman-mother in her life reaches 11.1%.

    Prolapse causes:

    • Pregnancy with large fetus, childbirth
    • Obesity
    • Frequent weight lifting
    • Hormonal environment
    • Smoking
    • Previous pelvic operations
    • Constipation
    • Chronic cough (bronchial asthma, emphysema)

    Prolapse symptoms

    • Frequent cystitis
    • Urine loss and pain during intercourse
    • Difficulty urinating - “stuffiness”
    • Frequent urination and urgency
    • Disturbances in defecation (rectocele)

    Hysterectomy favours prolapse, because the bladder “loses its support”, while the percentage of women requiring correction of prolapse after hysterectomy is around 6 - 8%

    PROLAPSE TREATMENT: Surgical repair is the appropriate treatment for genital prolapse. The golden rule is to repair from the abdomen with suspension (lifting) of the organs with a mesh, as well as the laparoscopic and robotic method with the daVinci system, specialised and performed by very few centres in Greece, due to the high level of surgeons’ training, constitutes significant offer of our Hospital, as it is successfully performed over the last 8 years from our urological team. This technique repairs automatically all 3 types of prolapse (cystocele, uterine prolapse, rectocele). The three-dimensional image of the surgical field, the perfectly coordinated, accurate and steady movements of robotic arms that replicate the surgeon’s movements, and the greater ease provided by the robot for multiple sutures and mesh support, render the success of this operation excellent, with the following advantages:

    • Minimal blood loss
    • Short hospitalisation (1-2 days)
    • Minimal postoperative pain
    • Fewer relapses
    • Preservation of the outcome in time
    • Less pain on contact
    • Very small percentages of INFECTION AND MESH REJECTION 

    The experience of the Athens Medical Centre urology team makes it a pioneer in Europe, as the European Association of Urology has posted on its site a video showing a robotic prolapse surgery performed at the surgery unit and by the team of Athens Medical Centre as an exemplar video, due to the integrity and accuracy of this surgical operation.

    26.03.15
    Athens Medical Centre: For the first time in Greece a robotic surgery for radical prostatectomy in a patient with colostomy and previous abdominoperineal resection of the rectum

    Athens, March 26, 2015 - For the first time in Greece, the team of Dr. Nick Pardalidis, Athens Medical Centre, performed a robotic radical prostatectomy surgery in a patient with colostomy and previous abdominoperineal resection of the rectum.

    The high level of difficulty of radical prostatectomy surgery, which was due to the heavy medical history of the patient, lasted 3 hours, while the patient recovered fully on the same day and was discharged from the hospital on the following day.

    “Robotic surgery, which is the method of choice in the treatment of localised prostate cancer, can now be applied safely and effectively in difficult cases such as this one, allowing the patient to leave the hospital immediately,” said Dr. Nick Pardalidis, Director of the Urology Department of Athens Medical Centre. 

    It is worth noting that robotic radical prostatectomy method was firstly applied in Greece by the team of Dr. Nick Pardalidis nearly 10 years ago, when the 1st Robotic system arrived in the country, at Athens Medical Centre. 

    28.01.15
    Prevention and Robotic Surgery for localized prostate cancer

    George N. KyriakouMD, PhD, FEBUHead of Minimally Invasive Urologic Surgery, Athens Medical Centre

    In Europe, it is the most common type of cancer with an incidence of 214 cases per 1000 men, followed by lung and colorectal cancer (1). Further, prostate cancer is the 2nd cause of death from cancer in the male population (2). Since 1985 there is an increase in the number of deaths from prostate cancer even in countries where it is not so frequent (3).

    Prostate cancer most often affects older men and especially in developed countries where life expectancy is greater (4). There are large differences in parts of Europe and, particularly in Sweden, where the age of death is prolonged and death cases related to smoking few in number, prostate cancer is the most common malignancy in the male population, constituting 37% of all new cancer cases in 2004 (5).

     Risk Factors

     Few have been identified.  The three main ones are:

     - Advanced age
     - Place of origin
     - Inheritance

    The incidence of prostate cancer increases greatly depending on the number of occurrences in the same family, and up to 5.11 times (6,7).  9% of men with prostate cancer have true heredity (3 or more relatives with disease or at least two of the same family with cancer before age 55 years)  (7). Geographically it is found  most  often  to  USA  and  N. Europe  and  less in South. East Asia (8). Probably therefore exogenous factors affect the risk and progression of disease in clinically important cancer, such as diet, sexual behavior, alcohol consumption, exposure to radiation, chronic inflammation (9,10 ) and occupational exposure (10).
    The prostate cancer becomes a candidate carcinoma for exogenous preventive measures, such as dietary and pharmacological prevention, reduced calorie intake and fatty foods, cooked meat, minerals and vitamins (carotenoids, retinoids, vitamins C, D, and E), fruits and vegetables , calcium and selenium etc., but still many studies analyze these factors as potential preventive measures (11).  Interestingly, the metabolic syndrome (obesity, hyperlipidemia, diabetes) might be related to prostate diseases such as benign hyperplasia and cancer (12,13).  In conclusion, we do not know yet if there is sufficient certainty to recommend dietary measures to reduce the risk of developing prostate cancer (14), but it seems that these measures currently highlighted in men who have relatives with prostate cancer (7,8).

    Screening and early diagnosis

    A first assessment of PSA has been determined to be in the age of 40, as basic level (15).  If PSA is <1ng/ml it is recommended to repeat it after eight years (16).  Further, measurement of PSA after 75 years is not recommended because early diagnosis of cancer would not have significant impact on the clinical evolution of the disease (17).

    Diagnosis

    The main diagnostic tools of prostate cancer are the digital rectal examination, PSA blood test and biopsies.

     - Digital rectal examination (DRE)
    It is a necessary clinical prostate evaluation and becomes positive when tumor volume is over 0,2 mL. More than 18% of patients are guided to biopsies with suspicious DRE alone irrespective of PSA value, which might be normal or low, and this rate is important. A suspect DRE must lead to biopsies because it is often predictive of more aggressive tumor (18, 19).
     
     - PSA
    The truth is that once applied, PSA measurement was a revolution in the detection era of prostate cancer.
    It is a protease produced exclusively by prostatic cells.  It is specific related to prostate but not only with prostate cancer, because it can increase in several pathologies such as benign prostatic hyperplasia, prostate infection, etc. The higher the value, the greater the chance for prostate cancer.  Absolute cutoff does not exist (20,21).
    More information can be provided by the Free PSA/PSA ratio, especially when the value of PSA  is between 4 and 10 and with negative DRE.  56% of patients with quotient <0.10 had prostate cancer, and only 8% with a quotient> 0.25.  It makes no sense to measure the free PSA, when the value of  PSA> 10. In addition, free PSA may be varied in large prostates (22).  Also important is the increase of PSA velocity (23).
    A new biomarker is the PCA3 with its detection in urine after prostatic massage.  Elevated levels increase the potential for repeat biopsy when there is strong suspicion of prostate cancer. (24-27).

    Prostate biopsies

    So far the above diagnostic tests emerge the suspicion of prostate cancer.  The definitive diagnosis is performed with prostate biopsies.  These are performed ​​with the help of ultrasound through the rectum by applying local anesthesia in the region of the prostate gland.  Local anesthesia favorates this diagnostic test very well tolerated.  Before proceeding to prostate biopsy should take into account the biological age of the patient, general health satus and the plan of our therapeutic measurements.
     The recommendation for prostate biopsies are high PSA levels and suspicious DRE. A first high PSA value might not be an absolute indication for biopsies. PSA measurement should be repeated after a few weeks in the same laboratory and after recommendation for abstinence from ejaculation, prostate manipulations (recent DRE, bladder catheterization, inflammation, etc.), since these conditions alone can increase the value of PSA (28,29).
     Problem arises when biopsies are negative, with great suspicion of cancer, even in small focus in the prostate. So when should be repeated biopsies;
     A. Continuous increase of PSA
     B. Suspect DRE
     C. Atypical cells in previous biopsy (ASAP)
     D. Existence of extensive high-grade intraepithelial neoplasia in the foregoing biopsies (PIN) (30)

    Recently, in cases of suspected malignancy and before prostate biopsies a multiparametric magnetic resonance imaging of prostate is applied. It might detect suspicious areas in the prostate gland with greater sensitivity and accuracy than classic MRI, focus of interest during biopsies.

    Surgical treatment - Robotic Surgery

    Over the last 10 years, developments in  biotechnology have given a significant boost in surgical techniques. Urology eminently have beneficial supply of this evolution by improving the lithotripter, the use of laser, the application of laparoscopic surgery and finally the induction of the robotic da Vinci system.


            Laparoscopic Urology

    Perhaps it is misunderstood, as a first impression by many patients, that "the robot performs surgery", having entered on scenarios almost of science fiction.  The entire procedure depends on the experience, skills and knowledge of the robotic urologist surgeon.  The robotic da Vinci system surgery is based on the principles of laparoscopic surgery.  Through skin holes, as in laparoscopy, robotic surgical instruments are placed into the abdominal cavity of the patient, which in turn are connected to the arms of the robotic system - thus, the patient is "linked" to the robot. The assistant surgeon also works over the patient.


            Assistant surgeon next to the robotic system

    The robotic urologist "Surgeon" is sitting at a console away from the patient, which provide an excellent in sharpness three-dimensional surgical field, while surgeon’s movements made ​​via ring fittings are copied and transmitted with absolute precision  by the robot.  So urologist is operating and the robot is performing.


            Robotic surgeon at the console

    The cost of the robotic da Vinci system is slightly greater than that of laparoscopic surgery. The learning curve for robotics is less than that of laparoscopy. Between the two pathways, based on the same principles of implementation (surgery through skin holes-monitors-telesurgery) no particular differences exist for specific procedures. The benefit, for example, between robotic and laparoscopic surgery in the treatment of varicocele or renal cyst removal does not differ in favor to robotics, furthermore latter is more expensive.
    But for specific procedures, the advantages of robotic surgery are important.

     What are really the advantages of robotic surgery and why a patient would prefer to be cured surgically by the da Vinci system?

    • The visibility of the surgical field is in multiple growth with excellent sharpness (high  definition) and is "three-dimensional", as the surgeon is situated inside the abdominal cavity of the patient.
    • The urologist performs surgery without experiencing fatigue from standing and stillness, while seated.


            Comfortable surgery for the surgeon with three-dimensional view of the surgical field

    • The robotic arms, copying the movements of the surgeon, fully absorb the factor "human trembling hands".
    • Robotic camera with its great ability can reach the most inaccessible sites of the surgical field, resulting in the maximum of organs and tissues dissection.
    • The da Vinci surgical system provides the greatest surgical ergonomy, with movement to 7 axes, which cannot take place in open and laparoscopic surgery.


            Movement to 7 axes

    • In addition to the above benefits, robotic surgery offers all the advantages of «minimally  invasive  surgery », as  minimum postoperative pain, reduced metabolic stress, quick hospital discharge, rapid return to daily activities, reduced transfusion rate and excellent cosmetic result.

    As said above, the induction of the robotic system has specific indications.  Procedures, as radical prostatectomy and partial nephrectomy for selective removing kidney tumors with organ preservation are surgical treatments of choice with the robotic da Vinci system. It is important to be mentioned that in the US 85% of prostate cancer cases are performed by robotic surgery.

    In conclusion we should keep in mind the following: a biotechnological instrument has been devised by the human mind, to primarily serve and cure patients, providing benefits in recovery from major diseases with the less hassle.  So, such a great surgical tool has to be used by surgeons with experience and knowledge, always based on the rules governing the principles of surgery. The robotic da Vinci system simply complements the skill of the surgeon rather than the latter the robotic system. And it finds perfect indication in localized prostate cancer with the above benefits for patients, but also for the performance of the Urologist.

    Robotic Surgery and Prostate Cancer

     The most appropriate indication for robotic treatment in urology is localized prostate cancer.  This is due to the following reasons:

            a. The prostate is an inaccessible organ situated very deeply and low in the pelvis behind the pubic symphysis.  The robotic camera and accessories provide significant surgical approach and dissection.
            b.  The extremely high resolution, the multiple surgical movements and great ergonomy provided by the robotic da Vinci system function as a perfect "tool" in two important parameters combined to this surgery: urinary continence and erectile ability.

    These two parameters depend on sufficient maintenance of vessels and erectile nerves (neurovascular bundles), good preservation of the bladder neck, enough long urethral stump, preservation of puboprostatic ligaments and fascia of prostate and pelvis.  These anatomical factors contribute in the rapid recovery of continence, as in increased probability of erectile refunction.  It is noteworthy that when indicated by oncology rules, bilateral preservation of erectile bundles could rise the erectile recovery even from the first postoperative month, robotically.
    Concerning the oncological outcomes, it seems at present by the literature that there is no statistically significant difference between open and robotic prostatectomy. It is important to mention that in cases where prostate cancer should be performed with concomitant removal of pelvic lymph nodes, robotics offer excellent, detailed and rapid lymphadenectomy with low morbidity. Studies also prove a benefit in favor to robotic radical prostatectomy for locally advanced disease, as well as salvage prostatectomy (ie after irradiation).

    References

    1. Boyle P, Ferlay J. Cancer incidence and mortality in Europe 2004. Ann Oncol 2005 Mar;16(3):481-8.
    2. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin 2008 Mar-Apr;58(2):71-96.
    3. Quinn M, Babb P. Patterns and trends in prostate cancer incidence, survival, prevalence and mortality.Part I: international comparisons. BJU Int 2002 Jul;90(2):162-73.
    4. Parkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000: the global picture. Eur J Cancer 2001Oct;37(Suppl 8):S4-66.
    5. Persson G, Danielsson M, Rosén M, et al. Health in Sweden: The National Public Health Report 2005.Scand J Public Health 2006; 34(Suppl 67):3-10.
    6. Jansson KF, Akre O, Garmo H, et al. Concordance of tumor differentiation among brothers with prostate cancer. Eur Urol 2012 Oct;62(4):656-61.
    7. Hemminki K. Familial risk and familial survival in prostate cancer. World J Urol 2012 Apr;30(2):143-8.
    8. Kheirandish P, Chinegwundoh F. Ethnic differences in prostate cancer. Br J Cancer 2011 Aug;105(4):481-5.
    9.  Nelson WG, De Marzo AM, Isaacs WB Prostate cancer. N Engl J Med 2003 Jul;349(4):366-81.
    10. Leitzmann MF, Rohrmann S. Risk factors for the onset of prostatic cancer: age, location, and behavioral correlates. Clin Epidemiol 2012;4:1-11.
    11. Schmid HP, Engeler DS, Pummer K, et al. Prevention of prostate cancer: more questions than data.Recent Results Cancer Res 2007;174:101-7.
    12. De Nunzio C, Aronson W, Freedland SJ, et al. The correlation between metabolic syndrome andprostatic diseases. Eur Urol 2012 Mar;61(3):560-70.
    13. Alcaraz A, Hammerer P, Tubaro A, et al. Is there evidence of a relationship between benign prostatic hyperplasia and prostate cancer? Findings of a literature review. Eur Urol 2009 Apr;55(4):864-73.
    14. Richman EL, Kenfield SA, Stampfer MJ, et al. Egg, red meat, and poultry intake and risk of lethal prostate cancer in the prostate-specific antigen-era: incidence and survival. Cancer Prev Res (Phila) 2011 Dec;4(12):2110-21.
    15. Börgermann C, Loertzer H, Hammerer P, et al. [Problems, objective, and substance of early detectionof prostate cancer]. Urologe A 2010 Feb;49(2):181-9. [Article in German]
    16. Roobol MJ, Roobol DW, Schröder FH. Is additional testing necessary in men with prostate-specific antigen levels of 1.0 ng/mL or less in a population-based screening setting? (ERSPC, section Rotterdam). Urology 2005 Feb;65(2):343-6.
    17. Schaeffer EM, Carter HB, Kettermann A, et al. Prostate specific antigen testing among the elderly; when to stop? J Urol 2009 Apr:181(4):1606-14;discussion 1613-4.
    18. Okotie OT, Roehl KA, Han M, et al Characteristics of prostate cancer detected by digital rectal examination only. Urology 2007 Dec;70(6):1117-20.
    19. Gosselaar C, Roobol MJ, Roemeling S, et al. The role of the digital rectal examination in subsequent screening visits in the European randomized study of screening for prostate cancer (ERSPC),Rotterdam. Eur Urol 2008 Sep;54(3):581-8.
    20. Stamey TA, Yang N, Hay AR, et al. Prostate-specific antigen as a serum marker for adenocarcinoma ofthe prostate. N Engl J Med 1987 Oct;317(15):909-16.
    21. Catalona WJ, Richie JP, Ahmann FR, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol 1994 May;151(5):1283-90.
    22. Catalona WJ, Partin AW, Slawin KM, et al. Use of the percentage of free prostate-specific antigen to enhance differentiation of prostate cancer from benign prostatic disease: a prospective multicentre clinical trial. JAMA 1998 May 20;279(19):1542-7.
    23. Carter HB, Pearson JD, Metter EJ, et al. Longitudinal evaluation of prostate-specific antigen levels in men with and without prostate disease. JAMA 1992 Apr 22-29;267(16):2215-20.
    24. Deras IL, Aubin SM, Blase A, et al. PCA3: a molecular urine assay for predicting prostate biopsy outcome. J Urol 2008 Apr;179(4):1587-92.
    25. Hessels D, Klein Gunnewiek JMT, van Oort I, et al. DD3 (PCA3)-based molecular urine analysis for the diagnosis of prostate cancer. Eur Urol 2003 Jul;44(1):8-15; discussion 15-6.
    26. Nakanishi H, Groskopf J, Fritsche HA, et al. PCA3 molecular urine assay correlates with prostate cancer tumor volume: implication in selecting candidates for active surveillance. J Urol 2008 May;179(5):1804-9; discussion 1809-10.
    27. Hessels D, van Gils MP, van Hooij O, et al Predictive value of PCA3 in urinary sediments in determining clinico-pathological characteristics of prostate cancer. Prostate 2010 Jan 1;70(1):10-6.
    28. Eastham JA, Riedel E, Scardino PT, et al. Polyp Prevention Trial Study Group. Variation of serum prostate-specific antigen levels: an evaluation of year-to-year fluctuations. JAMA 2003 May 28:289(20):2695-700.
    29. Stephan C, Klaas M, Muller C, et al. Interchangeability of measurements of total and free prostate specific antigen in serum with 5 frequently used assay combinations: an update. Clin Chem 2006 Jan;52(1):59-64.
    30. Merrimen JL, Jones G, Walker D, et al. Multifocal high grade prostatic intraepithelial neoplasia is a significant risk factor for prostatic adenocarcinoma. J Urol 2009 Aug;182(2):485-90

    27.01.15
    Robot - Assisted Partial Nephrectomy

    Achilles PloumidisMD, BSc, MSc, PhD, FEBU Urologist Center for Robotic & Laparoendoscpic Urologic Surgery (CRoLUS) Athens Medical Center

    Precision in the resection of the tumor maximizes the function result of the kidney.

    The role of the kidney

    The kidneys are biological filters of the human body, that filter 200 liters of blood in a daily basis, thus removing harmful and unwanted metabolic products by excreting them through the urine. Their role also extends in aiding in the production of red blood cells, activating vitamin D and producing substances that regulate the arterial blood pressure. Both kidneys (right and left) are anatomically situated on either side of the lumbar spine just under the diaphragm and are covered with fat for protection.

    Renal Cancer

    Renal cancer or tumor of the kidney is the 8th most common cancer in men and the third most common cancer of the urinary tract. Statistically it is observed after the 6th decade of life and it affects men twice more often than women.The most common renal tumor, corresponding to 85% of all type of renal cancers is the Renal Cell Carcinoma (RCC). Every year, 30.000 new cases of RCC are diagnosed only in Europe while studies reveal that in the USA this number exceeds 65.000.

    Risk Factors for RCC

    According to recent studies contributing factors for renal cancer are: smoking, high arterial blood pressure, dietary factors, obesity, family history, advanced kidney disease (renal insufficiency) and certain types of syndromes. Additionally, workplace exposure to certain substances, such as Cadmium, increases the risk for RCC.However, having a risk factor or even several risk factors doesn’t mean that someone will get the disease.

    Symptoms of RCC

    The most common symptoms of renal cancer are: hematuria (blood in the urine), pain or sense of heaviness in the lumbar region, palpable mass in the abdomen, sudden loss of weight, weakness, fever, high blood pressure or even anemia.Nonetheless, it is important to highlight that today in most cases, RCC is asymptomatic and is incidentally found on imaging studies (ultrasound, computed tomography etc.).If diagnosed on time and with prompt therapy, renal cancer can be cured. Specifically, recent data suggest that RCC cure rates can reach up to 80% or even 100%.

    Diagnosis of RCC

    Imaging studies are the front line defense in the diagnosis of renal cancer. Abdominal ultrasound (US) is very often offered to patients due to low cost and relatively high sensitivity. When a suspicious mass is observed further imaging studies are suggested such as: computed tomography (CT), intravenous urography (IVU) or even magnetic resonance imaging (MRI). The former imaging studies can not only reveal a possible metastasis of the tumor but with the help of advanced software, can also offer the surgeon a three-dimensional (3D) reconstruction of the tumor, aiding in the decision making for the best surgical therapy. 

    Therapy of RCC

    When the tumor is confined to the kidney and its anatomical position and size allows for radical resection with minimal harm to the organ, partial nephrectomy is indicated. This means that the surgeon removes only the tumor and not the entire kidney, thus leaving intact healthy renal tissue and avoiding future renal insufficiency.

    Partial Nephrectomy

    Partial nephrectomy can be achieved by three kinds of surgical methods: conventional open surgery, laparoscopic surgery and robotic surgery. During the last decade with the implementation of new technologies in modern operating theaters and the advances in surgical technique, patients can appreciate the benefits of minimal invasive surgery. Contemporary operations avoid large incisions and unnecessary trauma to the tissue with consequent inflammation and aim in offering the same or even better oncological and functional results through the so called “button hole” surgery (Figure 1). Minimal access surgery is not solely about aesthetic results, but has proven its benefits especially in the post-surgical period for the patient, where the tissue stress as well as the total stress is minimal, thus giving the possibility for faster recovery. For the above-mentioned reasons, most centers in Europe and in the USA have adopted minimal access surgery in most if not all operations.

    Robotic surgery is considered the evolution of laparoscopic surgery and although both methods are “minimal invasive”, robotic surgery indisputably concentrates more advantages for the surgeon as well as the patient. The surgeon with the use of the robotic platform,known as Da Vinci (Intuitive Surgical Inc.), sits comfortably in front of a console from which he performs the operation by manipulating specially designed joysticks (Figure 2). However, the robot does not function independently, nor is programed to operate on its own. Instead, the surgeon’s movements on the joysticks are transferred to the robotic arms with the aid ofa sophisticated software that is based on a “master-slave” protocol. This gives the ability to the surgeon to operate with unparalleled precision due to the elimination of natural hand tremor, while the scaled flawless motion of the robotic arms transmit in real time the surgeon’s actions to the operating field. Additionally, the console offers a three-dimensional environment thanks tothe specially designed robotic camera with unique optical clarity. The magnified, up to 15 times surgical field, givesreal depth of field revealing tissue details in order to perform micro-dissection when needed. Practically, the surgeon can access the kidney, through four small holes on the abdominal wall and subsequently resect the tumor and suture the remaining healthy organ with precision.

    Robot-assisted Partial Nephrectomy (RAPN)

    The procedure is performed under general anesthesia. In order to create the necessary space for the instruments, the abdominal cavity is filled with air (pneumoperitoneum), while the robotic camera and the robotic tools are inserted through four minor incisions on the skin. Initially the surgeon mobilizes the necessary tissues in order to gain access to the kidney. Afterwards, the surgeon proceeds with the clumping of the renal hilum (Figure 3). This part of the operation is mandatory in order to resect the tumor with the minimum blood loss and with accuracy and safety. After completing the removal of the tumor, the healthy remaining part of the kidney is sutured and reconstructed. The renal hilum is unclumped and the kidney is reperfused. The specimen is placed in a special endoscopic bag and removed from the abdomen.

    Throughout the procedure, the surgeon whilesitting in the console and operating can view the surgical field and at the same time observing the 3D reconstructed model of the tumor uploaded from the CT images done preoperatively. Thus the surgeon knows what to expect and can easily compare his operative field with the preoperative 3D tumor model. This capability (TilePro™, Intuitive Surgical Inc.) is offered by the current generation robotic platform (da Vinci Si HD, Intuitive Surgical Inc.)in Athens Medical Center and combines images reproduced by the Department of computed tomography. Subsequently a combination of accurately locating and identifying the tumor as well as meticulous dissection of the massis achieved with the aid of the robotic instruments.

    The advantages of robot-assisted partial nephrectomy

    The goal in any partial nephrectomy is to achieve:

    • Radical resection of the tumor (oncological result)
    • Preservation of as much as possible healthy renal tissue (functional result)
    • Minimization of the renal hilum clumping (warm ischemia time)

    Success in all of the above levels is accomplished thanks to the technological innovations of the robotic platform. The three-dimensional vision combined with the ergonomic position of the surgeon on the console offers optimum environment for a demanding operation such as RAPN. At the same time, the miniaturized wristed instruments (EndoWrist® Instruments, Intuitive Surgical Inc.) give the opportunity to dissect the tissue in every possible angle and render suturing of the renal defect easier, safer and bloodless. With the additional degrees of freedom that the wristed robotic instruments offer, the surgeon can tackle even more challenging tumors, thus extending the indications for partial nephrectomy. These features converge to a safer operation with minimal clumping time of the renal hilum and maximal functional result.

    The advantages of robot-assisted partial nephrectomy compared to conventional open and laparoscopic partial nephrectomy are significant for the patient. These include:

    • Maximizing the oncological and functional result with minimum warm ischemia time. The tumor is radically resected leaving only healthy tissue behind which is then reconstructed in order for the kidney to function again. Thus the kidney is preserved and potential renal insufficiency is averted. 
    • Minimal blood loss and less need for blood transfusion.
    • Significantly less postoperative pain and less need for consumption of analgesics.
    • Fast recovery. Hospital stay is usually 2-3 days, while convalescence to normal everyday work is rapid. This is due to the fact that major trauma and incisions are avoided.
    • Better aesthetic result. By avoiding large, sometimes more than 20 cm, incisions (used in open surgery) and have the operation done through four small incisions in the skin the likelihood of hernia is diminished.
    • Less postoperative complications (depending also on surgeon’s experience.

    14.01.15
    Laser prostatectomy with the latest generation XPS Green Light Laser

    Pardalidis Nikolaos M.D,Ph.D,FEBUMDDirector of Urology Department.

    Benign Prostatic Hyperplasia (BPH)

    Prostate is a small gland of the genitourinary male system which is located just inferior to the urinary bladder. Prostate produces the spermatic fluid which provides mobility to the sperm during ejaculation. The normal prostate weights 15-20gr approximately. The prostate gland is afflicted with either benign or malignant neoplasms. Benign Prostatic Hyperplasia is a common situation in men and is age-related (80% in men over 80years).

    BPH can cause severe prostatic symptoms as well as obstructive voiding symptoms in many patients. Those symptoms are due to prostatic gland enlargement, leading to a reduced urine flow from the prostatic urethra.

    Lower urinary tract symptoms (LUTS)

    The main symptoms of BPH can be irritative and/or obstructive

    • Frequency
    • Nocturia
    • Urgency
    • Hesitancy
    • Decreased force and caliber of stream
    • Sensation of incomplete bladder emptying
    • Pain or burning during urination
    • Urine leak as a result of overflow

    Therapy for BPH with the latest generation XPS Green Light Laser

    Prostatectomy with the Green Light Laser has been established as a method for treating BPH the last decade in Greece and also worldwide, overcoming 500000 patients successfully. In comparison with other surgical techniques, XPS Green Light Laser combines the best results with the minimum side effects.

    This method is currently used with absolute success in Athens Medical Center. Our new acquirement, the latest generation of XPS Green Light Laser, increases the effectiveness of the method even in difficult cases.

    Technique

    The method is accomplished through a small optic fiber which is inserted in the prostatic urethra via a cystoscope. The optic fiber carries high power laser energy which heats the prostatic tissue, resulting in his rapid vaporization. The urine flow is restored immediately and most of the patients are instantly relieved from their symptoms.

    Advantages of the new XPS laser system

    The latest generation XPS Green Light Laser is the most modern system in the treatment of BPH. Its technology provides excellent conditions for a successful and safe laser prostatectomy. The new system has increased power (180 watt) and a new high tolerance hydroprotective optic fiber, which gives the ability to handle even high volume prostate glands in short operative time. This is highly important for those patients who the only alternative until now was open surgery. In this way, the reduction of the operative time minimizes the burden of the patients.

    ​Finally, the new system has highly safety features which guarantee a bloodless operation field, even in difficult cases such as high risk patients (patients who receive anticoagulant therapy, patients with pacemakers or patients with multiple health problems).

    In contrast with other surgical techniques which require catheterization and hospital stay, the patient is discharged the same day (day clinic procedure) or the next morning, without urethral catheter.

    Summarizing the advantages of XPS Green Light Laser procedure:

    • Day clinic procedure
    • Short catheterization time
    • Bloodless and safe method
    • Painless method
    • Sexual function is not affected
    • Rapid restoration of urination
    • Fast return to normal activities
    • Effective therapy (instant relief from symptoms)

    Results

    The results of the method are excellent. The patient is relieved from his symptoms instantly (within 24 hours). Few hours after the operation the patient observes improvement of the urine flow. He is discharged from the hospital the same or the next day without catheter and he is able to return to his normal activities the next couple of days. Mild postoperative symptoms such as burning during urination, small amount of blood in the urine or urgency, usually last for a few days and retreat spontaneously.

    In conclusion, prostatectomy with the latest generation XPS laser is a trustworthy, bloodless, painless and safe method of treating BPH with excellent results for the patients.