Surgery Workshop
Multiquadrant combined robotic radical prostatectomy and left partial nephrectomy: a combined procedure by a single approach
Cirugía robótica multicuadrante concomitante para prostatectomía radical y nefrectomía parcial izquierda. Dos procedimientos mediante un solo abordaje
R. Valero, G. Sawczyn, J. Garisto, R. Yau, J. Kaouk
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Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Valero, G. Sawczyn, J. Garisto, R. Yau, J. Kaouk" "autores" => array:5 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Valero" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Sawczyn" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Garisto" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Yau" ] 4 => array:4 [ "nombre" => "J." 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Dos procedimientos mediante un solo abordaje" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 600 "Ancho" => 905 "Tamanyo" => 103528 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The da Vinci SP ® robot docked.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">SC</span>= SP cannula; <span class="elsevierStyleBold">SE</span>= SP Entry Guide; <span class="elsevierStyleBold">AP</span>= Advanced access platform; <span class="elsevierStyleBold">A</span>= Auxiliary laparoscopic port.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Robotic surgery has been increasingly used in urology for the treatment of multiple diseases, especially in oncological procedures such as radical prostatectomy where more than 80% of cases are performed using the robotic approach.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In addition, robotic technology has facilitated and overcome some of the difficulties present in laparoscopic partial nephrectomy and is considered a valid option that has expanded the indications of this surgical procedure. The incidence of coexisting different primary tumors during the evaluation and staging of prostate cancer is very low.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The association of prostate cancer and renal cell carcinoma is rare and the decision of performing one or two surgical times could be offered to some patients after a thorough evaluation of the case and adequate surgical planning. The recent approval by the FDA of the SP® da Vinci Surgical System for single port approach could offer advantages such as a single incision and simplifying the surgical planning. We present, to our knowledge, the first case of a concomitant robotic radical prostatectomy and a left robotic partial nephrectomy performed by a single port approach using the SP® surgical platform.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patient</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 66-year-old male with a diagnosis of localized prostate cancer and a suspicious left renal mass incidentally found on computed tomography (CT) scan during prostate cancer evaluation. Body Mass Index (BMI) was 27.40, and American Urological Association (AUA) symptom score 12, and sexual health inventory for men (SHIM) questionnaire score 23. Past medical history was positive for hypertension and no surgical history. PSA was 6.68 ng/ml, digital rectal exam showed a symmetrical, enlarged prostate without nodules.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A TRUS guided biopsy with magnetic resonance imaging (MRI) fusion reported adenocarcinoma Gleason 8 (4 + 4), grade group 4, in 4 out of 17 cores with maximum core involvement of 40%. An MRI demonstrated two PI-RADS 3 lesions in the transitional zone, 10 mm each with no other abnormal findings. A bone scan was negative for metastatic lesions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">An abdominal and pelvic CT scan with IV contrast showed evidence of an enhancing complex left renal cyst with a possible hemorrhagic component. A retroperitoneal ultrasound showed a 4.5 cm solid, vascular, left renal mass with no cystic component (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical technique</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Positioning and approach</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was placed in lithotomy and Trendelenburg position with both arms tucked and a 3 cm supraumbilical incision two finger breadths above the umbilicus was made, dissection of the abdominal wall was carefully performed until reaching the intraperitoneal space. Port-placement: a GelPOINT standard (purple) advanced access platform (Applied Medical, Rancho Santa Margarita, CA) was inserted and a dedicated 25-mm multichannel robotic single-port cannula was placed through the gel-seal cap. An additional 12 mm laparoscopic port was inserted in the left hemi-abdomen close to the GelPOINT, and the da Vinci SP® surgical system (Intuitive Surgical, Sunnyvale, CA) was docked (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) Robotics instruments were introduced and the radical prostatectomy was performed replicating the technique previously described for trans-peritoneal single port prostatectomy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">After we undocked the robot for the extraction of the prostate, the surgical table was rotated so as to have the patient leaning towards the right side, facilitating retrieval of the specimen and simultaneously positioning the patient for the partial nephrectomy. The robot was re-docked to perform the second procedure without changes in the OR distribution or additional port placement. The partial nephrectomy was done using the technique previously described with the use of the SP® da Vinci surgical system.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">Total operative time was 256 minutes (min) with a console time of 108 min for radical prostatectomy, and 101 min for the partial nephrectomy respectively, including a warm ischemia time of 26 min. Total estimated blood loss was 250 cc: around 100 cc for radical prostatectomy and 150 cc for partial nephrectomy. A blood transfusion was not needed. During the postoperative period, there was an increase in creatinine level from 1.28 mg/dL to 4.58 mg/dL associated with oliguria, after conservative management the creatinine level dropped to 1.49 mg/mL.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Final pathology report for prostate was adenocarcinoma pT3N0, Gleason 7 (4 + 3) grade group 3, positive extra-prostatic extension (focal) with negative margins, negative lymph nodes (0/4), classified as a pT3N0. Prostate volume was 77 g. The pathology report for the kidney lesion was renal cell carcinoma, papillary type, 4.8 cm, ISUP grade 2, negative margins, classified as a pT1b. Two months after surgery, PSA was undetectable and no complications or recurrence from the renal cell carcinoma were detected.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Robotic surgery has proven its feasibility for both radical prostatectomy and partial nephrectomy. Nowadays, the robotic approach is considered the main option to perform radical prostatectomy in the US.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Regarding partial nephrectomy, it is becoming more popular after proving feasibility and safety.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Probably all these are related with the benefits of minimally invasive approaches such as less bleeding, minimal pain, shorter length of stay, and faster recovery. In addition, reconstruction of the urinary tract (e.g, urethrovesical anastomosis, renorrhaphy) may be considered more comfortable, ergonomic, and associated with an easier learning curve when using the robotic platforms.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Despite this, performing concurrent renal and prostatic surgery using laparoscopic or robotic approach is not common, although there are few clinical cases reported.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8,9</span></a> To our best knowledge, we report the first case of a single-port combined radical prostatectomy and partial nephrectomy using the SP® platform.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Multiple surgical approaches are always challenging and surgical planning is crucial for optimal surgical outcomes and there are several acceptable options: open or laparoscopic, one stage or multi-staged. When faced with concurrent lesions in different sites, it can be even more challenging. As it was a radical prostatectomy and left partial nephrectomy of a lower pole kidney lesion, we chose to perform both surgeries at the same time, by a single port approach, using the SP® Platform. Other reports have been made Oda et al. presented a combination a hand-assisted laparoscopic radical nephrectomy and open radical prostatectomy for the treatment of a prostate cancer a left renal mass reducing the number of ports and reducing morbidity.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Also, pure robotic approaches have been used for the treatment of synchronous tumor; 2009 Patel et al. reported a right partial nephrectomy and a radical prostatectomy using 5 trocars, with two robotics arms reusing just one incision for a total of 9 different incisions.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The difference of a multi-arm robotic approach surgical planning and the single-port robotic approach surgical planning can be seen in <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>. By choosing the multi-arm robotic approach, it would be necessary to have between 6 to 8 ports in order to be able to perform both procedures — as a recent report made by Akpinar et al. reusing 4 of the initial ports in a combined procedure.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> With this approach, one would need to undock and re-dock all the four arms between procedures and probably change the patient positioning to a 60–90º flank position which could be an important factor to impact total operative time. Our total operative time was 256 minutes which is shorter than other publications 260 and 288 minutes in a two cases see report)<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and (335 min).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">When using the da Vinci S® and Si® platform, the patient-cart position would have changed from between feet to lateral position between procedures - the da Vinci Xi platform has a wider range of arm movements and would be able to perform both surgeries without changing the patient-cart position, but still having the same issues regarding the placement of new ports and undocking and re-docking the four arms. By choosing the single-port approach using the da Vinci SP® platform, a single main 3 cm incision is planned for the single-port cannula placement and a single additional port for the bed-assistant serves well for both surgeries.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The da Vinci SP® has a 360º range of motion that allows an easy transition between procedures, and a flexible camera (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>) that allows for less steep bed position compared to conventional approaches, and enable just leaning the table to one side in this case for extraction of the prostate and redocking. Only one robotic arm needs to be undocked and docked, making this step faster.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Comparison to other reports in the literature on combination surgery reveal the advantages of the da Vinci SP® ease of transitioning, such as one published by Jung in 2014.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> They published 3 cases using a single site approach for the partial nephrectomy and then a standard multi-arm approach for the radical prostatectomy. They had a median operative time of 334 minutes and a median console time of 200 minutes. Their time out of the console time was 134 minutes. In our case, we only spent 47 minutes out of the console which showcases how much time is saved by the single port platform in laparoscopic access, patient positioning, and skin closure.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The use of an extra port outside the GelPoint was chosen in this case, but recently, we have changed our methods which does not routinely use this extra port to perform either radical prostatectomy or partial nephrectomy using the da Vinci SP® Platform. Rather, now we routinely place the assistant port for the bedside assistant parallel with the single-port multichannel cannula through the GelPoint and thus maintaining a true single incision, single-port surgery adding potential benefits related with postoperative pain and cosmesis. Adding an ‘off-site’ or ‘+1’ port is optional, but usually used only when necessary and the decision should be based on case complexity and surgeon experience.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">In our experience, the single port approach has the advantages of easier surgical planning and transition for combined and multi-quadrants surgeries; also faster recovery, minimal pain in the postoperative setting, minimal need for opioids, and an excellent cosmetic outcome.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The availability of a purpose-built single port device - the da Vinci SP® Platform - gives us another option for the approach of concurrent intra-abdominal surgeries, especially for different quadrants, making us consider using a single incision for the approach of bilaterally or upper and lower tract concomitant surgeries, in selected cases. However, we suggest that combined procedures should be performed only in high volume institutions by surgeons with vast experience in robotic surgery.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1315537" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patient and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1214194" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1315538" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Paciente y Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1214193" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patient" ] 1 => array:3 [ "identificador" => "sec0020" "titulo" => "Surgical technique" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Positioning and approach" ] ] ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-22" "fechaAceptado" => "2019-06-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1214194" "palabras" => array:5 [ 0 => "SP® robot" 1 => "Single-port" 2 => "Combine procedure" 3 => "Radical prostatectomy" 4 => "Partial nephrectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1214193" "palabras" => array:5 [ 0 => "Robot SP®" 1 => "Puerto único" 2 => "Cirugía multicuadrante" 3 => "Prostatectomía radical" 4 => "Nefrectomía parcial" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To present the first case of a concomitant robotic radical prostatectomy and a left robotic partial nephrectomy performed by a single-port approach using the SP® da Vinci surgical system (Intuitive Surgical, Sunnyvale CA).</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patient and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A 66-year-old male diagnosed with localized prostate cancer and a left kidney renal mass incidentally found on computed tomography (CT) scan during prostate cancer evaluation. Procedures were performed using a single supra-umbilical 3 cm incision, plus one additional laparoscopic port, utilizing a standard Gelpoint® (Applied Medical, Rancho Santa Margarita, CA) and replicating the technique previously described for single-port transperitoneal radical prostatectomy and partial nephrectomy with the use of the SP® robotic platform.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Total operative time was 256 minutes (min) with a console time of 108 min for radical prostatectomy, and 101 min for the partial nephrectomy respectively, including a warm ischemia time of 26 min. Estimated blood loss was 250cc. Blood transfusion was not needed. Final pathology for prostate was adenocarcinoma Gleason 7 (4 + 3) and for the kidney lesion was renal cell carcinoma. After two months of follow-up, PSA was undetectable and no complications or recurrence were detected.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The single-port approach has advantages as easier surgical planning and transition for combined and multi-quadrants surgeries: faster recovery, minimal postoperative pain and need for opioids, and excellent cosmetic outcome. We suggest that combined procedures should be performed only in high volume institutions by surgeons with vast experience in robotic surgery in selected patients.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patient and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Presentar el primer caso de cirugía multicuadrante concomitante —prostatectomía radical robótica y nefrectomía parcial robótica izquierda— realizadas con técnica de puerto único utilizando el sistema quirúrgico da Vinci SP® (Intuitive Surgical, Sunnyvale CA).</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Paciente y Metodología</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Masculino de 66 años con diagnóstico de cáncer de próstata localizado y lesión sospechosa en riñón izquierdo encontrada en tomografía axial computarizada (TAC) durante evaluación de cáncer de próstata. Ambos procedimientos se realizaron usando una sola incisión de 3 centímetros, y un puerto laparoscópico adicional; utilizando un Gelpoint® estándar (Applied Medical, Rancho Santa Margarita, CA) y replicando la técnica previamente descrita de puerto único para prostatectomía radical robótica y nefrectomía parcial con el uso de la plataforma Robótica puerto único prostatectomía SP®.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Tiempo operatorio total fue 256 minutos (min); con un tiempo de consola de 108 min para la prostatectomía radical, y 101 min para la nefrectomía parcial respectivamente, incluyendo un tiempo de isquemia de 26 min. Pérdida sanguínea estimada fue 250 cc. No sé necesito transfusión. Patología final de próstata fue adenocarcinoma Gleason 7 (4 + 3) y para la lesión renal fue carcinoma de células renales. Después de dos meses de seguimiento, PSA fue indetectable, sin recurrencia o complicaciones.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La técnica de puerto único presenta ventajas como mas fácil planificación quirúrgica y transición para cirugías combinadas y multicuadrantes, recuperación mas rápida, dolor postoperatorio mínimo y menor uso de opioides, además de excelentes resultados cosméticos. Sugerimos que procedimientos combinados deberían ser realizados solo en instituciones con un alto volumen de pacientes, por cirujanos con amplia experiencia en cirugía robótica y en pacientes seleccionados.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Paciente y Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Valero R, Sawczyn G, Garisto J, Yau R, Kaouk J. Cirugía robótica multicuadrante concomitante para prostatectomía radical y nefrectomía parcial izquierda. Dos procedimientos mediante un solo abordaje. Actas Urol Esp. 2020;44:119–124.</p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1421 "Ancho" => 905 "Tamanyo" => 154915 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">MRI showing two 1 cm PI-RADS 3 lesion.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1079 "Ancho" => 1505 "Tamanyo" => 199005 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">A.</span> Ultrasound showing a 4.5 cm solid, vascular, left renal mass with no cystic component. <span class="elsevierStyleBold">B.</span> Sagital <span class="elsevierStyleBold">C.</span> Axial and <span class="elsevierStyleBold">D.</span> Coronal CT views showing a complex left renal cyst with a possible hemorrhagic component.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 600 "Ancho" => 905 "Tamanyo" => 103528 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The da Vinci SP ® robot docked.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">SC</span>= SP cannula; <span class="elsevierStyleBold">SE</span>= SP Entry Guide; <span class="elsevierStyleBold">AP</span>= Advanced access platform; <span class="elsevierStyleBold">A</span>= Auxiliary laparoscopic port.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1860 "Ancho" => 1500 "Tamanyo" => 249655 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">A.</span> Multi-arm robotic combined radical prostatectomy and left partial nephrectomy port placement planning. <span class="elsevierStyleBold">B.</span> A Single-port approach using the da Vinci SP® Robot for radical prostatectomy and left partial nephrectomy port placement planning.</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 770 "Ancho" => 1305 "Tamanyo" => 155530 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The da Vinci SP® single port arms showing the double articulating jointed instruments and the flexible camera.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Robot-assisted radical prostatectomy: advances since 2005" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L-M. 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| 2023 March | 1 | 0 | 1 |
