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Thomas E Ahlering

Publications and source records attributed to Thomas E Ahlering.

18 recordsLinked to original sources
PubMed2006

Post-robotic prostatectomy urinary continence: characterization of perfect continence versus occasional dribbling in pad-free men.

OBJECTIVES: To review and characterize two groups of men who report being pad-free after robot-assisted laparoscopic prostatectomy (RLRP): those with occasional incontinence and those with complete control. METHODS: The study included 106 out of a total of 195 men who underwent RLRP. Inclusion requirements were adequate follow-up and no-pad continence status. All patients completed self-administered American Urological Association symptom score (AUAss) and continence questionnaires and underwent measurement of peak urinary flow rates, postvoid residual volumes, and voided volumes (VV) before and 3 months after surgery. All data and standard clinical characteristics were entered prospectively into an electronic database. RESULTS: Two distinct groups reported wearing no pads: the "perfect" group (n = 32) reported never leaking, and the "imperfect" group (n = 74) reported occasional leakage but did not wear pads. Preoperatively, the "imperfect" group was older (62.2 versus 59 years) and had more urinary symptoms (all P < 0.05). Postoperatively, the "imperfect" group took longer to achieve a pad-free status (median 39.8 versus 19.3 days), had larger prostates (mean 50.9 versus 43.2 g), had lower VV (324 versus 405 mL), and more urinary symptoms (AUAss 7.4 versus 4.3; all P < 0.05). CONCLUSIONS: Sixty-nine percent of men who attain "pad-free continence" after RLRP have occasional urinary leakage. Preoperatively, these men are characteristically older and have larger prostates, AUAss, and bother scores. Postoperatively, the "imperfect" group takes longer to achieve pad-free status and has smaller bladder capacities and more urinary symptoms. These results suggest that an overactive detrusor is the likely contributing etiology.

Humans↗
PubMed2006

Impact of cautery versus cautery-free preservation of neurovascular bundles on early return of potency.

PURPOSE: To update our short-term potency outcomes from a cautery-free (CFT) versus bipolar cautery technique to preserve the neurovascular bundles (NVB) during robotic laparoscopic radical prostatectomy (RLP). PATIENTS AND METHODS: Previously, we reported on 3-month potency outcomes in 23 men, which we now extend to 51 men. All men met three criteria: age <66 years, Sexual Health Inventory in Men (SHIM-5) score of 22 to 25, and either unilateral or bilateral NVB preservation at LRP. Group 1 (N = 51), the study group, had preservation of the NVB with CFT. Group 2 (N = 36) had traditional dissection using bipolar cautery. The average age and preoperative SHIM scores were similar for the two groups. Data were collected prospectively via validated questionnaires. Potency was defined as an erection adequate for vaginal penetration. All men were asked to estimate the fullness of erections compared with baseline (preoperative). RESULTS: The average age and preoperative SHIM scores were similar for both groups. The rate of potency at 3 months was 47% (24/51) in group 1 versus just 8.3% (3/36) in group 2 (P < 0.001). Additionally, only 9 of 25 CFT patients (36%) reported zero fullness compared with 15 of 22 patients (68%) in the bipolar cauterytreated group (P = 0.03). CONCLUSIONS: With expanded experience, there was no change in 3-month return of sexual function (47%) compared with our initial publication. This result further supports the importance of avoiding cautery when controlling the vascular pedicle and dissecting the NVB.

Adult↗
PubMed2005

Impact of obesity on clinical outcomes in robotic prostatectomy.

OBJECTIVES: To assess the preoperative parameters and clinical outcomes of patients undergoing robotic laparoscopic radical prostatectomy with specific attention to the body mass index (BMI). Little is known about the impact of obesity (BMI greater than 30) on the clinical outcomes of patients undergoing radical prostatectomy. METHODS: The data of 100 men undergoing robotic laparoscopic radical prostatectomy between June 2002 and October 2003 were prospectively entered into a database. The standard clinical characteristics (eg, prostate-specific antigen, Gleason score) and perioperative and postoperative parameters were evaluated. Additionally, all were assessed preoperatively and postoperatively for American Urological Association symptom and bother scores, uroflowmetry, postvoid residual urine volume, and sexual function. RESULTS: Nineteen men were obese (BMI greater than 30) and 81 were not (BMI less than 30). The two groups had a similar need for transfusion, length of stay, and pathologic outcome. However, the obese men had poorer baseline urinary function (peak flow rate 13.9 versus 18.3 mL/s; voided volume 306 versus 454 mL; P < or =0.05) and sexual function (Sexual Health Inventory of Men score 14.1 versus 18.2; P < or =0.05). Obese men had significantly more complications (26.3% versus 4.9%; P = 0.01) and required more time to return to baseline activities (7 versus 4.3 weeks; P = 0.09) and urinary function. Finally, at 6 months, only 47% of obese patients versus 91.4% of nonobese patients had achieved pad-free urinary continence (P < or =0.001). CONCLUSIONS: In this study, obese patients had significantly worse baseline urinary and sexual function, had complications, and did not recover urinary function as quickly or as well as nonobese patients. Obese patients also demonstrated a strong trend toward a delay in recovery time.

Adult↗
PubMed2005

Feasibility study for robotic radical prostatectomy cautery-free neurovascular bundle preservation.

INTRODUCTION: Efforts continue to develop techniques that maintain the neurovascular bundles and minimize trauma for robotic laparoscopic radical prostatectomy. We evaluated the feasibility of preserving the nerve bundles without cautery or surgical clips. TECHNICAL CONSIDERATIONS: The seminal vesicles were dissected using scissors and bipolar cautery. After the rectum was mobilized, the vascular pedicles (VPs) were delineated. Laparoscopic bulldog clamps (30 mm) were placed at least 1 cm from the prostate. Using scissors, the VPs were divided right at the prostate. The neurovascular bundle was gently dissected off the prostatic capsule. After mobilizing the bundle, FloSeal was applied along its entire length. The FloSeal was then covered with a dry 1 x 4-cm sheet of Gelfoam. Once the prostate was removed, the bulldog clamps were sequentially withdrawn. The VPs were observed, and, if pulsatile bleeding was encountered, a 3-0 figure-of-eight suture was precisely placed for hemostasis. When hemostasis was complete, the anastomosis was performed. RESULTS: In 17 men, temporary vascular occlusion was applied to 27 VPs and FloSeal and Gelfoam was applied each time. In 4 cases (15%), hemostasis was inadequate because of continued arterial bleeding that was easily controlled with a superficial figure-of-eight ligature of 3.0 absorbable suture. The average estimated blood loss was 91 mL (range 75 to 150). CONCLUSIONS: Cautery-free, clip-free, nerve-sparing robotic laparoscopic radical prostatectomy is feasible using a combination of temporary occlusion of the thick posterior prostatic pedicles with bulldog clamps followed by application of FloSeal. The effect on potency needs further follow-up.

Adult↗
PubMed2005

Initial impact of a dedicated postgraduate laparoscopic mini-residency on clinical practice patterns.

BACKGROUND AND PURPOSE: Laparoscopic surgical techniques are difficult to master, especially for surgeons who did not receive this type of training during their residencies. We have established a 5-day mentor-preceptor- proctor-guided postgraduate "mini-residency" (M-R) experience in minimally invasive surgery. The initial results from the first 16 participants in the laparoscopic M-R modules are presented. PARTICIPANTS AND METHODS: On the first and the last day of the M-R, all participants underwent surgical skills testing using an open-surgery, standard laparoscopic, and robot-assisted laparoscopic format. A written examination was also administered on the last day. The influence of M-R on the participants' practice pattern was then assessed by a follow-up questionnaire survey 1 to 7 months after their attendance. RESULTS: Data from the first 16 participants were analyzed. Of note, the score was significantly improved for only one of the four tested laparoscopic skills (i.e., threading a suture through loops). Nonetheless, on the follow-up survey, of the 15 respondents, two laparoscopically naïve participants had performed laparoscopic nephrectomy, and of the eight participants who had prior renal-ablative laparoscopic experience, four had performed advanced reconstructive laparoscopic cases. CONCLUSIONS: A 5-day dedicated postgraduate M-R in laparoscopy appears to be helpful for urologists wishing to incorporate this surgical approach into their practices. The "take rate" among participants is initially at the 40% level, similar to what has been previously reported after a 1 to 2-day hands-on didactic laparoscopy course.

Adult↗
PubMed2004

Role of robotics in laparoscopic urologic surgery.

Robotic surgery is in its infancy. Small series of cases are emerging from various centers that indicate a strong role for robotics in the future of urology, surgery, and general medicine. Robotic technology is progressing on every level and will continue to be a driving force in the progress of science and medicine.

Equipment Design↗
PubMed2004

Robot-assisted versus open radical prostatectomy: a comparison of one surgeon's outcomes.

OBJECTIVES: To compare internally one surgeon's standard open radical prostatectomy (RP) and robot-assisted laparoscopic RP (RLP) results. RLP, like standard laparoscopic RP, ultimately needs to produce similar or improved results compared with standard RP techniques. Little information comparing RLP with standard RP exists. METHODS: As an internal control, we selected the last 60 standard RPs performed by one surgeon (T.A.) before initiating RLPs. For the RLP group, we selected cases 46 to 105 (n = 60) after the learning curve had adequately matured. We compared the clinical characteristics, perioperative results, and early clinical outcomes. RESULTS: The study and control groups had similar clinical characteristics (age, body size, preoperative prostate-specific antigen level, clinical stage, and Gleason score). No statistically significant differences were found between groups for prostate size, pT stage, Gleason score, or margin status (16.7% versus 20%; P = nonsignificant). The RLP group had a statistically significant advantage for estimated blood loss (103 versus 418 mL), postoperative hemoglobin change (1.6 versus 3.3 mg/dL), and hospital stay (1.02 versus 2.2 days). Complete continence (0 pads) at 3 months of follow-up and the rate of postoperative complications were similar for the RLP and RP groups (76% versus 75% and 6.7% versus 10%, respectively). CONCLUSIONS: We present the results of RLP and RP performed by one surgeon. With only a 100-case experience, RLP had oncologic and urinary outcomes that were at least equal to those after RP. RLP offers the benefits of minimally invasive surgery and does not compromise clinical or pathologic outcomes.

Adult↗
PubMed2004

Robotic laparoscopic radical prostatectomy with a single assistant.

INTRODUCTION: As experience with robot-assisted laparoscopic radical prostatectomy (rLRP) grows, the importance of the role of the assistant cannot be overstated. Key elements of the operation, dependent on the assistant, have not been reported. The focus of this report was to describe the key elements, which include positioning of the patient and assistant port sites, appropriate equipment, and the assistant-dependent steps of the procedure. TECHNICAL CONSIDERATIONS: During the course of the initial 100 cases, we reviewed the patient and port site positioning and reviewed the videotapes to identify key elements of the assistant's role that facilitate rLRP. We identified three important elements pertaining to patient positioning. In contrast to standard port site recommendations, we found that dominant and nondominant handedness dictate the assistant port site locations. Finally, we identified specific steps of the procedure that require the assistant to have laparoscopic skills necessary for the console surgeon to dissect the bladder neck, seminal vesicles, rectum, and neurovascular bundles. CONCLUSIONS: The assistant in rLRP is critical to the success of rLRP, especially in the learning phases. Right or left-handed dominance determines on which side the assistant should be positioned. In contrast to the console surgeon, the assistant should have intermediate to advanced laparoscopic skills.

Dissection↗
PubMed2004

Robotic radical prostatectomy: a technique to reduce pT2 positive margins.

OBJECTIVES: To describe a technique using the da Vinci robotic system that enhances one's ability to visualize and dissect the apex and reduce surgical margins. An important outcome of radical prostatectomy is the reduction of iatrogenic positive margins in organ-confined prostate cancer. TECHNICAL CONSIDERATIONS: The clinical data of our first 140 consecutive robot-assisted radical prostatectomies were divided into two groups: group 1, cases 1 to 50; and group 2, cases 51 to 140. After reviewing the surgical margin data and appropriate video clips of our initial 50 patients, we altered our technique. Initially, we had used two sutures to control the dorsal venous complex (DVC), one proximally and distally. The prostate was freed, and, finally, the DVC and urethra were divided. However, a bundle of fat obscured the apex, leading to positive apical margins. We developed the following method. First, we removed all of the fat overlying the DVC and prostate. Second, we divided the puboprostatic ligaments and dissected the levator fibers to expose and increase the DVC length fully. Finally, we stapled and divided the DVC using a vascular stapler. RESULTS: The two groups were clinically comparable. Overall, the pathologic margin rate improved from 36% in group 1 to 16.7% in group 2. In group 1, 9 (27.3%) of 33 pT2 tumors had positive margins versus 3 (4.7%) of 64 pT2 tumors in group 2 (P = 0.003). CONCLUSIONS: The data demonstrate that this change in technique for robotic prostatectomy resulted in a more defined apical dissection and a statistically significant reduction in positive margins in patients with organ-confined disease.

Adult↗
PubMed2004

Anatomic guide for port placement for daVinci robotic radical prostatectomy.

BACKGROUND AND PURPOSE: At present, robotic arm port placement for daVinci trade mark robot-assisted laparoscopic radical prostatectomy is based on the umbilicus. However, the robotic arm has a maximum manufactured required working distance of 25 cm. Accordingly, normal variability of patient height, weight, and umbilical location can leave the working arms too short to reach the membranous urethra. We present data to support port placement using the pubis, rather than the umbilicus, as the landmark. MATERIALS AND METHODS: If we assume the 25-cm working distance of the robot arm (Z) equals the hypotenuse of a triangle and the Y axis is the sum of the distance from the membranous urethra to the skin (Y1) plus the displacement of the skin secondary to CO(2) insufflation (Y2), then the horizontal distance X is from the robot port site to the pubis. To ascertain Y1, we randomly selected the CT scans of 25 men and measured the depth from the skin over the pubis to the membranous urethra. To determine Y2, we measured the change in height from the table of the port site after CO(2) insufflation in 11 robotic laparoscopic prostatectomies. RESULTS: The average distance of Y1 was 11 cm; Y2 was 6 cm. Using the formula (Z(2) - (Y1 + Y2)(2))(1/2), the maximum distance X from the port site to the pubis, for an average man, should not exceed 18 cm. CONCLUSION: The optimal landmark for calculating the placement of ports for the daVinci robotic arm placement should be the pubis and not the umbilicus. Tall men (>72 inches) are at risk for exceeding functional robot arm length, and in these men, port sites should not be more than 18 cm from the pubis.

Equipment Design↗
PubMed2004

Laparoscopic assisted radical cystectomy with ileal neobladder: a comparison with the open approach.

PURPOSE: To date, there have been only a few reports regarding the feasibility of the laparoscopic approach to radical cystectomy. In none of these cases has the laparoscopic approach been contrasted with a contemporary cohort of open cystectomy and diversion. Recently, we initiated laparoscopic assisted radical cystoprostatectomy and ileal neobladder (LACINB) wherein the cystoprostatectomy and pelvic lymph node dissections are performed laparoscopically and the reconstructive portion is performed via a 15 cm Pfannenstiel incision. We present and compare our initial series of LACINB with radical cystectomy performed by the open approach (OCINB) during the same period. MATERIALS AND METHODS: Between September 2001 and February 2003, 13 men underwent LACINB and 11 underwent OCINB at our institution. RESULTS: There was no statistically significant difference in operative time, blood loss or complication rates between the LACINB and OCINB groups. However, postoperative analgesic use was significantly less in the LACINB group. Time to start of a liquid diet, solid diet and length of hospitalization were also significantly less in the LACINB group vs the OCINB group. All margins in both groups were negative for bladder cancer, although 1 patient in the LACINB group had an incidentally found prostate cancer with a positive apical margin. CONCLUSIONS: LACINB is a feasible and reproducible procedure, which results in decreased postoperative pain and quicker recovery without a significant increase in operative time. However, longer followup is needed to assess long-term oncological and functional outcomes.

Aged↗
PubMed2003

Technique for laparoscopic running urethrovesical anastomosis:the single knot method.

OBJECTIVES: To describe a technique for facilitating the urethrovesical anastomosis at the time of laparoscopic radical prostatectomy. METHODS: Two 6-in. polyglycolic acid sutures (one dyed, one white) are tied together at their tail ends and delivered into the operative field by way of a 12-mm port. A running suture is completed from the 6:30 to the 12:00-o'clock position and from the 5:30 to the 12:00-o'clock position, at the end of which a single intracorporeal tie is completed. The catheter is placed before completing the anterior row of sutures; the catheter is left in place for 5 to 7 days. RESULTS: This anastomotic technique has been used in 122 laparoscopic radical prostatectomies and 8 robot-assisted laparoscopic radical prostatectomies. The average time for the anastomosis was 35 minutes (range 14 to 80). All anastomoses were watertight. No symptomatic postoperative urinary leaks have occurred, and no clinically evident clinical bladder neck contractures resulted. CONCLUSIONS: We describe a simple, watertight, running laparoscopic suture technique for accomplishing the urethrovesical anastomosis during laparoscopic radical prostatectomy.

Anastomosis, Surgical↗
PubMed2003

Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy.

PURPOSE: For a skilled laparoscopic surgeon the learning curve for achieving proficiency with laparoscopic radical prostatectomy (LRP) is estimated at 40 to 60 cases. For the laparoscopically naïve surgeon the curve is estimated at 80 to 100 cases. The development of a robotic interface might significantly shorten the LRP learning curve for an experienced open yet naïve laparoscopic surgeon. To our knowledge we report the initial experience with robot assisted LRP of a surgeon without laparoscopic experience. MATERIALS AND METHODS: Following a 1-day da Vinci (Intuitive Surgical, Mountain View, California) robotic laparoscopic training course and 2 cadaveric robotic LRPs an experienced oncologist (TEA) without laparoscopic experience performed 45 robotic LRPs. RESULTS: All procedures were successfully completed laparoscopically with no rectal injuries or transfusions. The learning curve to 4-hour proficiency was 12 patients and mean operating time subsequently was 3.45 hours (range 2.5 to 5.1). Mean blood loss was 145 cc (range 25 to 350), the mean postoperative day 1 decrease in hemoglobin was 2.6 mg/dl (range 1.9% to 5.1) and mean hospital stay was 36 hours (range 18 to 168). Mean Gleason score was 6.8, mean prostate volume was 50.5 gm (range 12.5 to 163) and the margin positive rate was 35.5%. Four patients (8.8%) had a total of 6 complications, which were managed conservatively. Catheterization time was 7 days (range 7 to 42). Continence (0 pads) was 33% at 1 week, 63% at 1 month and 81% at 3 months. CONCLUSIONS: A laparoscopically naïve yet experienced open surgeon successfully transferred open surgical skills to a laparoscopic environment in 8 to 12 cases using a robotic interface. This outcome is comparable to the reported experience of skilled laparoscopic surgeons after more than 100 LRPs.

Aged↗
PubMed2003

Radical prostatectomy stabilizes peak urinary flow rates.

OBJECTIVE: A community-based study of 2,119 men in Olmsted County reported that median peak urinary flow rates (PFR)s and voided volumes decrease steadily after age 40. We wanted to study how removal of the prostate via radical prostatectomy (RRP) would effect age-related reduction of PFRs and voided volumes. METHODS: One hundred men 1-9 years following RRP were evaluated for PFR, voided volume, post void residual, and AUA symptom score. RESULTS: Following removal of the prostate the mean PFR was 26.6 +/- 11 cc/sec and the mean voided volume was 345 +/- 174 cc. Analysis of PFR and voided volume versus age were stable over all ages. PFR and voided volume versus follow-up demonstrated a flat or slightly positive slope. PFRs post RRP were higher compared to the community-based data that reported mean PFRs that dropped steadily for men in their 50's, 60's and 70's (25.8 to 18.6 cc/sec, 26.3 to 16.1 cc/sec, 27.3 to 13.8 cc/sec, respectively p<.01). CONCLUSION: Following RRP, PFRs are, as expected, higher than historic controls and stable with advancing age and follow-up. This is in contrast to diminishing PFRs seen in normal men as they age. Our study suggests that age-related reduction in PFR and voided volumes is largely eliminated after total removal of the prostate gland.

Age Factors↗
PubMed2002

Seminal vesicle involvement in patients with D1 disease predicts early prostate specific antigen recurrence and metastasis after radical prostatectomy and early androgen ablation.

BACKGROUND: Controversy persists regarding the management of patients who present with locally advanced metastatic prostate carcinoma. Although radical prostatectomy is not curative, there is growing evidence that survival may be prolonged when the surgery is combined with early androgen ablation. In the current study, the authors present data with which to evaluate and define factors for disease progression in patients undergoing radical prostatectomy with lymph node positive disease who are treated with early endocrine ablation. METHODS: Data from 40 patients undergoing radical prostatectomy and early androgen ablation between 1987-1998, all of whom had lymph node positive disease, were analyzed. Age, preoperative prostate specific antigen (PSA) level, clinical and pathologic Gleason score, surgical margin, seminal vesicle involvement (SVI), and the number and percentage of involved positive lymph nodes were analyzed to predict PSA progression, metastasis, and death using univariate and multivariate statistical techniques. RESULTS: Univariate analysis identified only SVI as a statistically significant predictor of PSA progression and metastasis. Twenty-seven patients (67.5%) were found to have SVI. Multivariate analysis failed to identify other factors that added significantly to the predictive ability of SVI. Kaplan-Meier estimates of time to PSA recurrence and metastasis demonstrated that SVI was highly predictive of disease progression. The median time to PSA progression for the 27 patients with SVI was 7.5 years compared with no progression reported in the 13 patients without SVI (P = 0.011). CONCLUSIONS: VI is a very powerful predictor of disease progression in patients with lymph node positive disease who undergo radical prostatectomy and early androgen ablation. In the current study, preoperative PSA, clinical or pathologic Gleason scores, and other clinical factors were not found to be predictive of disease outcome.

Adenocarcinoma↗
PubMedDate not supplied

Rapid communication: early potency outcomes with cautery-free neurovascular bundle preservation with robotic laparoscopic radical prostatectomy.

PURPOSE: To report short-term potency outcomes with a cautery-free technique (CFT) to preserve the neurovascular bundles (NVB) during robotic laparoscopic radical prostatectomy (LRP). PATIENTS AND METHODS: All men were <66 years of age and had a Sexual Health Inventory in Men (SHIM) score of 22 to 25. They underwent unilateral or bilateral dissections. Group 1 (N = 23), the study group, had preservation of the NVB with CFT. Group 2 (N = 36) had traditional dissection using bipolar cautery. Data were collected prospectively via validated questionnaires. Potency was defined as an erection adequate for vaginal penetration. RESULTS: At 3 months, 10 patients (43%) in the CFT group reported potency versus just 3 (8.3%) in the bipolar-cautery group (P = 0.003). Additionally, only 2 (18%) of those having CFT reported zero penile fullness compared with 15 (68%) in the bipolar-cautery group (P = 0.01). CONCLUSIONS: The technique of controlling the vascular pedicle of the prostate and dissecting the NVB without cautery produced significant improvement in potency outcomes at just 3 months.

Adult↗