Perioperative outcomes following robot-assisted partial nephrectomy in elderly patients.

OBJECTIVE: To compare perioperative outcomes following robot-assisted partial nephrectomy (RAPN) in patients with age ≥ 70 years to age < 70 years. METHODS: Using Vattikuti Collective quality initiative (VCQI) database for RAPN we compared perioperative outcomes following RAPN between the two age groups. Primary outcome of the study was to compare trifecta outcomes between the two groups. Propensity matching using nearest neighbourhood method was performed with trifecta as primary outcome for sex, body mass index (BMI), solitary kidney, tumor size and Renal nephrometery score (RNS). RESULTS: Group A (age ≥ 70 years) included 461 patients whereas group B included 1932 patients. Before matching the two groups were statistically different for RNS and solitary kidney rates. After propensity matching, the two groups were comparable for baselines characteristics such as BMI, tumor size, clinical symptoms, tumor side, face of tumor, solitary kidney and tumor complexity. Among the perioperative outcome parameters there was no difference between two groups for operative time, blood loss, intraoperative transfusion, intraoperative complications, need for radical nephrectomy, positive margins and trifecta rates. Warm ischemia time was significantly longer in the younger age group (18.1 min vs. 16.3 min, p = 0.003). Perioperative complications were significantly higher in the older age group (11.8% vs. 7.7%, p = 0.041). However, there was no difference between the two groups for major complications. CONCLUSION: RAPN in well-selected elderly patients is associated with comparable trifecta outcomes with acceptable perioperative morbidity.

Comparison of perioperative outcomes following transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a propensity-matched analysis of VCQI database.

OBJECTIVE: To compare perioperative outcomes following retroperitoneal robot-assisted partial nephrectomy (RPRAPN) and transperitoneal robot-assisted partial nephrectomy (TPRAPN). METHODS: With this Vattikuti Collective Quality Initiative (VCQI) database, study propensity scores were calculated according to the surgical access (TPRAPN and RPRAPN) for the following independent variables, i.e., age, sex, side of the surgery, RENAL nephrometry scores (RNS), estimated glomerular filtration rate (eGFR) and serum creatinine. The study's primary outcome was the comparison of trifecta between the two groups. RESULTS: In this study, 309 patients who underwent RPRAPN were matched with 309 patients who underwent TPRAPN. The two groups matched well for age, sex, tumor side, polar location of the tumor, RNS, preoperative creatinine and eGFR. Operative time and warm ischemia time were significantly shorter with RPRAPN. Intraoperative blood loss and need for blood transfusion were lower with RPRAPN. There was a significantly higher number of intraoperative complications with RPRAPN. However, there was no difference in the two groups for postoperative complications. Trifecta outcomes were better with RPRAPN (70.2% vs. 53%, p < 0.0001) compared to TPRAPN. We noted no significant change in overall results when controlled for tumor location (anteriorly or posteriorly). The surgical approach, tumor size and RNS were identified as independent predictors of trifecta on multivariate analysis. CONCLUSION: RPRAPN is associated with superior perioperative outcomes in well-selected patients compared to TPRAPN. However, the data for the retroperitoneal approach were contributed by a few centers with greater experience with this technique, thus limiting the generalizability of the results of this study.

Perioperative outcomes following robot-assisted partial nephrectomy for complex renal masses: A Vattikuti Collective Quality Initiative database study.

Introduction: Outcomes of robot-assisted partial nephrectomy (RAPN) depend on tumor complexity, surgeon experience and patient profile among other variables. We aimed to study the perioperative outcomes of RAPN for patients with complex renal masses using the Vattikuti Collective Quality Initiative (VCQI) database that allowed evaluation of multinational data. Methods: From the VCQI, we extracted data for all the patients who underwent RAPN with preoperative aspects and dimensions used for an anatomical (PADUA) score of ≥10. Multivariate logistic regression was conducted to ascertain predictors of trifecta (absence of complications, negative surgical margins, and warm ischemia times [WIT] <25 min or zero ischemia) outcomes. Results: Of 3,801 patients, 514 with PADUA scores ≥10 were included. The median operative time, WIT, and blood loss were 173 (range 45-546) min, 21 (range 0-55) min, and 150 (range 50-3500) ml, respectively. Intraoperative complications and blood transfusions were reported in 2.1% and 6%, respectively. In 8.8% of the patients, postoperative complications were noted, and surgical margins were positive in 10.3% of the patients. Trifecta could be achieved in 60.7% of patients. Clinical tumor size, duration of surgery, WIT, and complication rates were significantly higher in the group with a high (12 or 13) PADUA score while the trifecta was significantly lower in this group (48.4%). On multivariate analysis, surgical approach (retroperitoneal vs. transperitoneal) and high PADUA score (12/13) were identified as predictors of the trifecta outcomes. Conclusion: RAPN may be a reasonable surgical option for patients with complex renal masses with acceptable perioperative outcomes.

Outcomes in robot-assisted partial nephrectomy for imperative vs elective indications.

OBJECTIVES: To assess and compare peri-operative outcomes of patients undergoing robot-assisted partial nephrectomy (RAPN) for imperative vs elective indications. PATIENT AND METHODS: We retrospectively reviewed a multinational database of 3802 adults who underwent RAPN for elective and imperative indications. Laparoscopic or open partial nephrectomy (PN) were excluded. Baseline data for age, gender, body mass index, American Society of Anaesthesiologists score and PADUA score were examined. Patients undergoing RAPN for an imperative indication were matched to those having surgery for an elective indication using propensity scores in a 1:3 ratio. Primary outcomes included organ ischaemic time, operating time, estimated blood loss (EBL), rate of blood transfusions, Clavien-Dindo complications, conversion to radical nephrectomy (RN) and positive surgical margin (PSM) status. RESULTS: After propensity-score matching for baseline variables, a total of 304 patients (76 imperative vs 228 elective indications) were included in the final analysis. No significant differences were found between groups for ischaemia time (19.9 vs 19.8 min; P = 0.94), operating time (186 vs 180 min; P = 0.55), EBL (217 vs 190 mL; P = 0.43), rate of blood transfusions (2.7% vs 3.7%; P = 0.51), or Clavien-Dindo complications (P = 0.31). A 38.6% (SD 47.9) decrease in Day-1 postoperative estimated glomerular filtration rate was observed in the imperative indication group and an 11.3% (SD 45.1) decrease was observed in the elective indication group (P < 0.005). There were no recorded cases of permanent or temporary dialysis. There were no conversions to RN in the imperative group, and seven conversions (5.6%) in the elective group (P = 0.69). PSMs were seen in 1.4% (1/76) of the imperative group and in 3.3% of the elective group (7/228; P = 0.69). CONCLUSION: We conclude that RAPN is feasible and safe for imperative indications and demonstrates similar outcomes to those achieved for elective indications.

Management of patients who opt for radical prostatectomy during the coronavirus disease 2019 (COVID-19) pandemic: an international accelerated consensus statement.

OBJECTIVE: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. The objective of this work is to develop guidance on criteria for prioritisation of surgery and reconfiguring management pathways for patients with non-metastatic prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve a low likelihood of coronavirus disease 2019 (COVID-19) hazard if radical prostatectomy (RP) was to be carried out during the outbreak and whilst the disease is endemic. METHODS: We conducted an accelerated consensus process and systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n = 34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. The Consensus opinion was defined as ≥80% agreement and this was used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and measures developed to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritisation criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as 'COVID-19 cold' sites. CONCLUSION: Reconfiguring management pathways for patients with prostate cancer is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing RP within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

Society of Robotic Surgery review: recommendations regarding the risk of COVID-19 transmission during minimally invasive surgery.

OBJECTIVES: To determine the risk of COVID-19 transmission during minimally invasive surgical (MIS) procedures METHODS: Surgical society statements regarding the risk of COVID transmission during MIS procedures were reviewed. In addition, the available literature on COVID-19 and other viral transmission in CO2 pneumoperitoneum, as well as the presence of virus in the plume created by electrocautery during MIS was reviewed. The society recommendations were compared to the available literature on the topic to create our review and recommendations to mitigate COVID-19 transmission. RESULTS: The recommendations promulgated by various surgical societies evolved over time as more information became available on COVID-19 transmission. Review of the available literature on the presence of COVID-19 in CO2 pneumoperitoneum was inconclusive. There is no clear evidence of the presence of COVID-19 in plume created by electrocautery. Technologies to reduce CO2 pneumoperitoneum release into the operating room as well as filter viral particles are available and should reduce the exposure risk to operating room personnel. CONCLUSION: There is no clear evidence of COVID-19 virus in the CO2 used during MIS procedures or in the plume created by electrocautery. Until the presence or absence of COVID-19 viral particles has been clearly established, measures to mitigate CO2 and surgical cautery plume release into the operating room should be performed. Further study on the presence of COVID-19 in MIS pneumoperitoneum and cautery plume is needed.

Predicting intra-operative and postoperative consequential events using machine-learning techniques in patients undergoing robot-assisted partial nephrectomy: a Vattikuti Collective Quality Initiative database study.

OBJECTIVE: To predict intra-operative (IOEs) and postoperative events (POEs) consequential to the derailment of the ideal clinical course of patient recovery. MATERIALS AND METHODS: The Vattikuti Collective Quality Initiative is a multi-institutional dataset of patients who underwent robot-assisted partial nephectomy for kidney tumours. Machine-learning (ML) models were constructed to predict IOEs and POEs using logistic regression, random forest and neural networks. The models to predict IOEs used patient demographics and preoperative data. In addition to these, intra-operative data were used to predict POEs. Performance on the test dataset was assessed using area under the receiver-operating characteristic curve (AUC-ROC) and area under the precision-recall curve (PR-AUC). RESULTS: The rates of IOEs and POEs were 5.62% and 20.98%, respectively. Models for predicting IOEs were constructed using data from 1690 patients and 38 variables; the best model had an AUC-ROC of 0.858 (95% confidence interval [CI] 0.762, 0.936) and a PR-AUC of 0.590 (95% CI 0.400, 0.759). Models for predicting POEs were trained using data from 1406 patients and 59 variables; the best model had an AUC-ROC of 0.875 (95% CI 0.834, 0.913) and a PR-AUC 0.706 (95% CI, 0.610, 0.790). CONCLUSIONS: The performance of the ML models in the present study was encouraging. Further validation in a multi-institutional clinical setting with larger datasets would be necessary to establish their clinical value. ML models can be used to predict significant events during and after surgery with good accuracy, paving the way for application in clinical practice to predict and intervene at an opportune time to avert complications and improve patient outcomes.

Clinical application of machine learning models in patients with prostate cancer before prostatectomy.

BACKGROUND: To build machine learning predictive models for surgical risk assessment of extracapsular extension (ECE) in patients with prostate cancer (PCa) before radical prostatectomy; and to compare the use of decision curve analysis (DCA) and receiver operating characteristic (ROC) metrics for selecting input feature combinations in models. METHODS: This retrospective observational study included two independent data sets: 139 participants from a single institution (training), and 55 from 15 other institutions (external validation), both treated with Robotic Assisted Radical Prostatectomy (RARP). Five ML models, based on different combinations of clinical, semantic (interpreted by a radiologist) and radiomics features computed from T2W-MRI images, were built to predict extracapsular extension in the prostatectomy specimen (pECE+). DCA plots were used to rank the models' net benefit when assigning patients to prostatectomy with non-nerve-sparing surgery (NNSS) or nerve-sparing surgery (NSS), depending on the predicted ECE status. DCA model rankings were compared with those drived from ROC area under the curve (AUC). RESULTS: In the training data, the model using clinical, semantic, and radiomics features gave the highest net benefit values across relevant threshold probabilities, and similar decision curve was observed in the external validation data. The model ranking using the AUC was different in the discovery group and favoured the model using clinical + semantic features only. CONCLUSIONS: The combined model based on clinical, semantic and radiomic features may be used to predict pECE + in patients with PCa and results in a positive net benefit when used to choose between prostatectomy with NNS or NNSS.

Ga68-PSMA PET for lymph node staging in intermediate and high-risk prostate cancer patients undergoing robotic assisted radical prostatectomy.

BACKGROUND: In intermediate/high risk prostate cancer, preoperative staging exams are mandatory. The aim of these imaging studies is to evaluate eventual lymph nodes involvement and/or metastatic spread of the tumor. Nevertheless, computed tomography (CT), magnetic resonance imaging (MRI), bone scan modalities have controversial sensitivity. Introduction of PET-PSMA and its use also as preoperative exam, seems to improve diagnostic accuracy due to favorable negative predictive value. The aim of this study was to evaluate the accuracy of PET-PSMA as a preoperative staging exam and its accuracy in predicting lymph nodes involvement in intermediate/high risk prostate cancer (PCa) patients. METHODS: A retrospective analysis of 50 patients diagnosed with intermediate/high risk PCa between 2018 and 2022 has been performed. All patients underwent preoperative 68Ga-PSMA PET/CT prior to robot-assisted radical prostatectomy (RARP) + extended pelvic lymph node dissection (ePLND). The cohort was categorized into two groups: pathologically negative lymph nodes (pN0) vs. positive nodes (pN1). A descriptive and comparative analysis was conducted. Correlation analysis between continuous variables was performed using the Spearman's Rank Test. Using lymph nodes histopathological results as reference standard, the diagnostic performance of 68Ga-PSMA PET/CT was calculated. RESULTS: Overall, 50 patients were included. The mean age was 63.3 years with a median prostatic specific antigen (PSA) of 7.7 ng/dL. Forty-four percent of the patients exhibited an International Society of Urological Pathology (ISUP) score of 4 or higher, and 28% had a pT3 stage. Overall, 43 (86%) patients submitted to ePLND did not present lymph node metastases (pN0), while 8 (14%) patients were pN1. PET-PSMA showed low sensitivity in detecting lymph node metastases (25%) while a high specificity in excluding lymph-node disease (88.1%) has been observed. Finally, we noted a significant positive correlation between the total SUVmax of the prostate and the initial total PSA (r=0.38; P=0.019), as well as the percentage of tumor involvement (r=0.383; P=0.022). CONCLUSIONS: Evidence on the role of PET-PSMA in the primary staging of PCa is steadily building up. A positive correlation between SUV and prostate involvement indicates that PET-PSMA could reflect, with a good approximation, the pathological features of the prostate. However, the low sensitivity depicted remains the main limitation. Future prospective studies are needed to determine the impact on patient outcome.

Risk Biomarkers for Biochemical Recurrence after Radical Prostatectomy for Prostate Cancer Using Clinical and MRI-Derived Semantic Features.

OBJECTIVES: This study aimed to assess the impact of the covariates derived from a predictive model for detecting extracapsular extension on pathology (pECE+) on biochemical recurrence-free survival (BCRFS) within 4 years after robotic-assisted radical prostatectomy (RARP). METHODS: Retrospective data analysis was conducted from a single center between 2015 and 2022. Variables under consideration included prostate-specific antigen (PSA) levels, patient age, prostate volume, MRI semantic features, and Grade Group (GG). We also assessed the influence of pECE+ and positive surgical margins on BCRFS. To attain these goals, we used the Kaplan-Meier survival function and the multivariable Cox regression model. Additionally, we analyzed the MRI features on BCR (biochemical recurrence) in low/intermediate risk patients. RESULTS: A total of 177 participants with a follow-up exceeding 6 months post-RARP were included. The 1-year, 2-year, and 4-year risks of BCR after radical prostatectomy were 5%, 13%, and 21%, respectively. The non-parametric approach for the survival analysis showed that adverse MRI features such as macroscopic ECE on MRI (mECE+), capsular disruption, high tumor capsular contact length (TCCL), GG ≥ 4, positive surgical margins (PSM), and pECE+ on pathology were risk factors for BCR. In low/intermediate-risk patients (pECE- and GG < 4), the presence of adverse MRI features has been shown to increase the risk of BCR. CONCLUSIONS: The study highlights the importance of incorporating predictive MRI features for detecting extracapsular extension pre-surgery in influencing early outcomes and clinical decision making; mECE+, TCCL, capsular disruption, and GG ≥ 4 based on pre-surgical biopsy were independent prognostic factors for early BCR. The presence of adverse features on MRI can assist in identifying low/intermediate-risk patients who will benefit from closer monitoring.

Robot-assisted partial nephrectomy in morbidly obese patients: a VCQI database study.

To compare perioperative outcomes following robot-assisted partial nephrectomy (RAPN) in patients with morbid obesity (body mass index (BMI > 40 kg/m2)) and non-obese patients. Using the Vattikuti Collective quality initiative (VCQI) database for RAPN, data for morbidly obese and non-obese patients was obtained. Propensity scores were calculated for two treatment groups (morbidly obese vs. non-obese) for the following variables i.e. age, sex, tumor size, RNS, surgical access (retroperitoneal/transperitoneal) and estimated glomerular filtration rate (eGFR) to ensure comparability. The primary outcome for the study was comparison of trifecta between the two groups. In this study, 158 morbidly obese patients were matched with 158 non-obese patients undergoing RAPN. Two groups matched well for age, sex, tumor size, eGFR and RNS. There was no difference between two groups for ischemia time, blood loss, blood transfusion, conversion to radical nephrectomy, length of stay, intraoperative and postoperative complications. Operative time was longer in morbidly obese patients (median 210 min vs. 120 min, p = 0.000). On pathological analysis, malignant tumors were more likely in the morbidly obese group (83.1% vs.73.4%, p = 0.018). Trifecta outcomes were comparable between the two groups (60.1% vs. 63.3%, p = 0.563). The Median duration of follow-up was 12 months (1-96 months). The morbidly obese group had significantly higher day one creatinine (1.25 ± 0.7 vs. 1.07 ± 0.37, p = 0.001) and significantly lower day one eGFR (62.1 ± 19 vs. 69.2 ± 21, p = 0.018). However, there was no difference between the two groups for the last follow-up creatinine and eGFR. RAPN in morbidly obese patients is associated with equivalent perioperative outcomes compared to non-obese patients.

Off-clamp Versus On-clamp Robot-assisted Partial Nephrectomy: A Propensity-matched Analysis.

BACKGROUND: Partial nephrectomy is the preferred treatment option for the management of small renal masses. On-clamp partial nephrectomy is associated with a risk of ischemia and a greater loss of postoperative renal function, while the off-clamp procedure decreases the duration of renal ischemia, leading to better renal function preservation. However, the efficacy of the off- versus on-clamp partial nephrectomy for renal function preservation remains debatable. OBJECTIVE: To compare perioperative and functional outcomes following off- and on-clamp robot-assisted partial nephrectomy (RAPN). DESIGN, SETTING, AND PARTICIPANTS: This study used the prospective multinational collaborative Vattikuti Collective Quality Initiative (VCQI) database for RAPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary objective of this study was the comparison of perioperative and functional outcomes between patients who underwent off- and on-clamp RAPN. Propensity scores were calculated for age, sex, body mass index (BMI), renal nephrometry score (RNS) and preoperative estimated glomerular filtration rate (eGFR). RESULTS AND LIMITATIONS: Of the 2114 patients, 210 had undergone off-clamp RAPN and others on-clamp procedure. Propensity matching was possible for 205 patients in a 1:1 ratio. After matching, the two groups were comparable for age, sex, BMI, tumor size, multifocality, tumor side, face of tumor, RNS, polar location of the tumor, surgical access, and preoperative hemoglobin, creatinine, and eGFR. There was no difference between the two groups for intraoperative (4.8% vs 5.3%, p = 0.823) and postoperative (11.2% vs 8.3%, p = 0.318) complications. Need for blood transfusion (2.9% vs 0, p = 0.030) and conversion to radical nephrectomy (10.2% vs 1%, p < 0.001) were significantly higher in the off-clamp group. At the last follow-up, there was no difference between the two groups for creatinine and eGFR. The mean fall in eGFR at the last follow-up compared with that at baseline was equivalent between the two groups (-16.0 vs -17.3 ml/min, p = 0.985). CONCLUSIONS: Off-clamp RAPN does not result in better renal functional preservation. Alternatively, it may be associated with increased rates of conversion to radical nephrectomy and need for blood transfusion. PATIENT SUMMARY: With this multicentric study, we noted that performing robotic partial nephrectomy without clamping the blood supply to the kidney is not associated with better preservation of renal function. However, off-clamp partial nephrectomy is associated with increased rates of conversion to radical nephrectomy and blood transfusion.

Development and Validation of a Nomogram Predicting Intraoperative Adverse Events During Robot-assisted Partial Nephrectomy.

BACKGROUND: Ability to predict the risk of intraoperative adverse events (IOAEs) for patients undergoing partial nephrectomy (PN) can be of great clinical significance. OBJECTIVE: To develop and internally validate a preoperative nomogram predicting IOAEs for robot-assisted PN (RAPN). DESIGN, SETTING, AND PARTICIPANTS: In this observational study, data for demographic, preoperative, and postoperative variables for patients who underwent RAPN were extracted from the Vattikuti Collective Quality Initiative (VCQI) database. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: IOAEs were defined as the occurrence of intraoperative surgical complications, blood transfusion, or conversion to open surgery/radical nephrectomy. Backward stepwise logistic regression analysis was used to identify predictors of IOAEs. The nomogram was validated using bootstrapping, the area under the receiver operating characteristic curve (AUC), and the goodness of fit. Decision curve analysis (DCA) was used to determine the clinical utility of the model. RESULTS AND LIMITATIONS: Among the 2114 patients in the study cohort, IOAEs were noted in 158 (7.5%). Multivariable analysis identified five variables as independent predictors of IOAEs: RENAL nephrometry score (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.25); clinical tumor size (OR 1.01, 95% CI 1.001-1.024); PN indication as absolute versus elective (OR 3.9, 95% CI 2.6-5.7) and relative versus elective (OR 4.2, 95% CI 2.2-8); Charlson comorbidity index (OR 1.17, 95% CI 1.05-1.30); and multifocal tumors (OR 8.8, 95% CI 5.4-14.1). A nomogram was developed using these five variables. The model was internally valid on bootstrapping and goodness of fit. The AUC estimated was 0.76 (95% CI 0.72-0.80). DCA revealed that the model was clinically useful at threshold probabilities >5%. Limitations include the lack of external validation and selection bias. CONCLUSIONS: We developed and internally validated a nomogram predicting IOAEs during RAPN. PATIENT SUMMARY: We developed a preoperative model than can predict complications that might occur during robotic surgery for partial removal of a kidney. Tests showed that our model is fairly accurate and it could be useful in identifying patients with kidney cancer for whom this type of surgery is suitable.

Salvage Robotic-Assisted Seminal Vesiculectomy for Merkel Cell Carcinoma Metastasis.

A 71-year-old male presented with Merkel cell carcinoma along with inguinal lymph node involvement (stage III). The patient was proposed for systemic treatment followed by inguinal lymphadenectomy and adjuvant radiotherapy. During the follow-up period, recurrences were documented (lymphatic and visceral) and were treated with salvage surgery and radiotherapy. On the fifth year of follow-up the patient was diagnosed with a metastasis in the right seminal vesicle and underwent stereotactic body radiation therapy. Two-years later, tumor recurrence in the right seminal vesicle was managed with salvage robotic assisted seminal vesiculectomy. Advanced stages of Merkel cell carcinoma have a poor outcome and salvage treatments should be tailored to each patient. A multidisciplinary approach was crucial in achieving successful outcomes. The patient is still recurrence free twenty-four months after surgery. To the best of our knowledge, this is the first publication reporting a seminal vesical Merkel cell metastasis.

Doente do sexo masculino de 71 anos, com carcinoma de células de Merkel com metastização ganglionar inguinal (estádio III), submetido a terapêutica sistémica seguida de linfadenectomia inguinal e radioterapia adjuvante. Durante o seguimento, todas as recorrências foram tratadas com radioterapia ou cirurgia de salvação. Cinco anos após o diagnóstico inicial, o doente foi diagnosticado com uma metástase na vesicula seminal direita, tendo sido tratado com radioterapia estereotáxica corporal. Dois anos mais tarde, por nova recorrência do tumor na vesicula seminal direita, foi submetido a uma vesiculectomia seminal robótica de salvação. Estádios avançados do carcinoma de células de Merkel apresentam um prognóstico reservado e os tratamentos de salvação devem ser adaptados a cada doente. Uma abordagem multidisciplinar revelou-se crucial para o sucesso do caso. O doente encontra-se no vigésimo quarto mês de pós-operatório, sem evidência de recidiva de doença. Até à data, este é o primeiro caso descrito de metástase na vesicula seminal de carcinoma de células de Merkel.

Early biomarkers of extracapsular extension of prostate cancer using MRI-derived semantic features.

BACKGROUND: To construct a model based on magnetic resonance imaging (MRI) features and histological and clinical variables for the prediction of pathology-detected extracapsular extension (pECE) in patients with prostate cancer (PCa). METHODS: We performed a prospective 3 T MRI study comparing the clinical and MRI data on pECE obtained from patients treated using robotic-assisted radical prostatectomy (RARP) at our institution. The covariates under consideration were prostate-specific antigen (PSA) levels, the patient's age, prostate volume, and MRI interpretative features for predicting pECE based on the Prostate Imaging-Reporting and Data System (PI-RADS) version 2.0 (v2), as well as tumor capsular contact length (TCCL), length of the index lesion, and prostate biopsy Gleason score (GS). Univariable and multivariable logistic regression models were applied to explore the statistical associations and construct the model. We also recruited an additional set of participants-which included 59 patients from external institutions-to validate the model. RESULTS: The study participants included 184 patients who had undergone RARP at our institution, 26% of whom were pECE+ (i.e., pECE positive). Significant predictors of pECE+ were TCCL, capsular disruption, measurable ECE on MRI, and a GS of ≥7(4 + 3) on a prostate biopsy. The strongest predictor of pECE+ is measurable ECE on MRI, and in its absence, a combination of TCCL and prostate biopsy GS was significantly effective for detecting the patient's risk of being pECE+. Our predictive model showed a satisfactory performance at distinguishing between patients with pECE+ and patients with pECE-, with an area under the ROC curve (AUC) of 0.90 (86.0-95.8%), high sensitivity (86%), and moderate specificity (70%). CONCLUSIONS: Our predictive model, based on consistent MRI features (i.e., measurable ECE and TCCL) and a prostate biopsy GS, has satisfactory performance and sufficiently high sensitivity for predicting pECE+. Hence, the model could be a valuable tool for surgeons planning preoperative nerve sparing, as it would reduce positive surgical margins.

Omission of Cortical Renorrhaphy During Robotic Partial Nephrectomy: A Vattikuti Collective Quality Initiative Database Analysis.

OBJECTIVES: To analyze the outcomes of patients in whom cortical (outer) renorrhaphy (CR) was omitted during robotic partial nephrectomy (RPN). METHODS: We analyzed 1453 patients undergoing RPN, from 2006 to 2018, within a large multi-institutional database. Patients having surgery for bilateral tumors (n = 73) were excluded. CR and no-CR groups were compared in terms of operative and ischemia time, estimated blood loss (EBL), complications, surgical margins, hospital stay, change in estimated glomerular filtration rate (eGFR), and need of angioembolization. Inverse probability of treatment weighting with Firth correction for center code was performed to account for selection bias. RESULTS: CR was omitted in 120 patients (8.7%); 1260 (91.3%) patients underwent both inner layer and CR. There was no difference in intraoperative complications (7.4% CR; 8.9% no-CR group; P = .6), postoperative major complications (1% and 2.8% in CR and no-CR groups, respectively; P = .2), or median drop in eGFR (7.3 vs 10.4 mL/min/m2). The no-CR group had a higher incidence of minor complications (26.7% vs 5.5% in CR group; P < .001). EBL was 100 mL (IQR 50-200) in both groups (P = .6). Angioembolization was needed in 0.7% patients in CR vs 1.4% in no-CR group (P = .4). Additionally, there was no difference in median operative time (168 vs 162 min; P = .2) or ischemia time (18 vs 17 min; P = .7). CONCLUSION: In selected patients with renal masses, single layer renorrhaphy does not significantly improve operative time, ischemia time, or eGFR after RPN. There is a higher incidence of minor complications, but not major perioperative complications after no-CR technique.

Retroperitoneal vs Transperitoneal Robot-assisted Partial Nephrectomy: Comparison in a Multi-institutional Setting.

OBJECTIVES: To evaluate retroperitoneal robot-assisted partial nephrectomy (RAPN) against transperitoneal approach in a multi-institutional prospective database, after accounting for potential selection bias that may affect this comparison. PATIENTS AND METHODS: Post-hoc analysis of the prospective arm of the Vattikuti Collective Quality Initiative database from 2014 to 2018. Six hundred and ninety consecutive patients underwent RAPN by 22 surgeons at 14 centers in 9 countries. Patients who had surgery at centers not performing retroperitoneal approach (n = 197) were excluded. Inverse probability of treatment weighting was done to account for potential selection bias by adjusting for age, gender, body mass index, comorbidities, side of surgery, location/size/complexity of tumor, renal function, American Society of Anesthesiologists score, and year of surgery. Operative and perioperative outcomes were compared between weighted transperitoneal and retroperitoneal cohorts. RESULTS: Ninety-nine patients underwent retroperitoneal RAPN; 394 underwent transperitoneal RAPN. Hospital stay in days-median 3.0 (Interquartile range [IQR] 2.0-4.0) transperitoneal vs 1.0 (1.0-3.0) retroperitoneal; P < .001, and blood loss in mL-125 (50-250) transperitoneal vs 100 (50-150) retroperitoneal; P = .007-were lower in the retroperitoneal group. There were no differences in operative time (P = .6), warm ischemia time (P = .6), intraoperative complications (P = .99), conversion to radical nephrectomy (P = .6), postoperative major complications (P = .6), positive surgical margins (P = .95), or drop in estimated glomerular filtration rate (P = .7). CONCLUSION: In a multi-institutional setting, both retroperitoneal and transperitoneal approach to RAPN have comparable operative and perioperative outcomes, except for shorter hospital stay with the retroperitoneal approach.

Robot-assisted brachytherapy of the bladder with long distance support using video conferencing.

PURPOSE: The frontline treatment for localized muscle-invasive bladder carcinoma (MIBC) is radical cystectomy. However, a significant percentage of this population is elderly with either severe co-morbidities or suboptimal general health, increasing the per- and post-operative risk when undergoing a radical cystectomy. Conservative treatment options have been implemented such as robot-assisted laparoscopic brachytherapy (RALB), a minimally invasive therapeutic approach ensuring excellent results in terms of local control, survival, and low morbidity. The treatment was supported successfully long distance using videoconferencing by an expert group from the Netherlands. MATERIAL AND METHODS: An 81-year-old man was treated with RALB. The patient was submitted to external beam radiotherapy (EBRT) in a total dose of 40 Gy in 20 fractions. A partial cystectomy followed by implantation of three catheters along the scar and brachytherapy was completed. A total dose of 25 Gy in 10 fractions was administered with dose points calculated at 5 mm from the catheters. RESULTS: Dose planning was characterized by an homogeneity index of 62.3% and overdose index of 19.7%. Other conformity indexes were analyzed. Patient was discharged at the fourth day after the procedure. The clinical response after 6 months was documented. CONCLUSIONS: The previously reported good rates of tumor control and survival, and the excellent tolerance and low morbidity support RALB as a promising approach for selected groups of patients with localized MIBC. This case illustrates the ability to expand efficiently this technique, particularly among inexperienced medical teams.