Scientific publications

PERINEAL ROBOTIC SURGERY FOR PROSTATE CANCER

Journal of Endourology

Third Prize: Perineal Robot-Assisted Laparoscopic Radical Prostatectomy: Feasibility Study in the Cadaver Model.

This was my Robotic Surgery Fellowship completion project, awarded in an annual essay contest by the Endourological Society, featured on the cover of its official journal "Journal of Endourology". This work, which I conceived in 2011-12, was an adaptation to the robotic surgery technique of open perineal surgery for prostate cancer, first done in 1904, by Dr. Hugh Young, later modified by Dr. Elmer Belt. The idea was promptly supported by Dr. Kaouk, who soon realized its potential for clinical application. The technique was first presented at the World Congress of Endourology in September 2012, in Istanbul, Turkey (p. 64, VS02-02) by my dear friend Dr. Riccardo Autorino. Between 2013-14, the technique was improved in experimental surgery models, with the help of colleagues from many countries, with emphasis on the contribution of Dr. Oktay Akça (Turkey), who already had extensive experience in open perineal surgery and was fundamental for the improvement of the technique. I then wrote the clinical research protocol, which was approved by the Cleveland Clinic IRB, and the technique was first used in patients by Dr. Kaouk in 2014. After passing initial clinical tests, the technique was also widespread in other countries, such as the UK and Turkey, where a study demonstrated advantages compared to the robotic abdominal technique (most commonly used), including shorter surgery and hospitalization time, lower blood loss, and quicker recovery of urinary continence and potency. It is important to note that these advantages still need to be confirmed by larger studies with a different methodology, however the initial findings are encouraging. Today, this is another weapon available in the prostate cancer-fighting arsenal.

COVER - NIRF - 1-s2.0-S0090429512X00116-

Robotic Real-time Near Infrared Targeted Fluorescence Imaging of Prostate Cancer

Urology

https://www.sciencedirect.com/science/article/abs/pii/S0090429512004426

This was another paper that featured on the cover and received editorial comment in "Urology", the "Société Internationale d'Urologie" official journal. It was an experimental study in mice on the use of a robotic imaging system for detection of near-infrared fluorescence of prostate tumors after intravenous injection of a marker directed to PSMA (prostate specific membrane antigen). At the time, this imaging system was still in its testing phase, and was later incorporated into the surgical robot, now known as the "Firefly system". In urology, its most used application is during surgery for removal of kidney tumors, where renal blood flow is temporarily interrupted, in whole or in part, for removal of the tumor with less blood loss. Another practical application is in the identification of lymph nodes, tumor marking and evaluation of adequate vascularization of bowel segments used in urinary tract reconstruction after surgery for bladder removal by invasive cancer. I had the privilege of writing the editorial comment of the paper that described this application for the first time. Dr. Robert J. Stein oriented me on this project.

TRANSVAGINAL robotic nephrectomy

Urology

https://www.sciencedirect.com/science/article/abs/pii/S0090429513001490

Experimental surgical technique for removal of the kidney through vaginal access. Professor Kaouk, one of the greatest enthusiasts of surgery without (or with minimal) scars, had already demonstrated the technique of vaginal removal of the kidney with laparoscopic instruments.

In robotics, he had already removed the kidney using a hybrid technique, with a robotic instrument via vaginal route and the other via umbilical incision. However, when we tried in the experimental surgery lab the single vaginal access with the robot, we faced two main limitations: collision of the robotic arms with the legs in gynecological position and difficulty in moving away the intestine to be able to reach the kidney area. Looking for alternatives to overcome these barriers, I went to review the anatomy atlas. After a few sketches (greatly improved by the brilliant medical illustrator Joseph Pangrace), I presented to Dr. Kaouk my ideas: to solve the problem of the collision of the robot with the legs, we would use a prone position (with the belly and legs down) and to solve the difficulty in moving away the intestine, we would access the kidney by the retroperitonium (space where the kidney is located, separated from the intestines by a thin membrane). He approved and we were able to overcome those initial barriers by completing the removal of the kidney. However, through a single small incision, robotic instruments can reach only a certain distance without the arms of that version of the robot (DaVinci Si) beginning to collide with each other. Using the traditional access route by incisions in the abdomen, there is no such problem, but when we insert the instruments through the vaginal route, it greatly increases the distance that they need to travel until reaching the kidney and the collision of the robotic arms greatly hinders the procedure. Therefore, we thought it would not be safe to try to implement this technique clinically at that time. For this to become feasible, robotic instruments need to be longer, which would allow a reach of all areas of the kidney through the vaginal access route safely. Robotic engineering has made considerable strides since then and the current robotic model Single Port (not available at that time) or a future version of it may be the solution that makes it possible to take this technique to clinical practice safely one day. Due to its originality, this work featured on the cover and received editorial comment in the journal "Urology". Although this project has not yet reached clinical application, it was from it that I had the idea to research the perineal pathway for robotic surgery, currently in clinical use.

Systematic review on the use of PDE-5 inhibitors in the treatment of urinary symptoms caused by prostate enlargement

BJU International

https://doi.org/10.1111/j.1464-410X.2010.09698.x

Phosphodiesterase 5 inhibitors for lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review

Humberto K. Laydner, Paulo Oliveira, Carlos Roberto A. Oliveira, Tafadzwa P. Makarawo, Weslley S. Andrade, Matheus Tannus, José Luciano R. Araújo

First published: 30 September 2010

This was my Urology Residency completion project . Although the subject of this project is not related to robotic surgery (my favorite area), I have a special memory of it. In addition to being the first article I sent for publication in an international urology journal, it brings me to the memory of dear friends, talented colleagues of the time of residence in "Bob's General Hospital", as we affectionately called our hospital. It was also the first systematic review on the subject in the medical literature and is still one of my most cited articles by other authors.