Toggling Technique Allows Retrograde Early Release to Facilitate Neurovascular Bundle Sparing During Robot-Assisted Radical Prostatectomy: A Propensity Score-Matching Study.

BACKGROUND: This study aimed to present the surgical facilitation of neurovascular bundle (NVB) sparing using the toggling technique (30° lens down/up switching) and to evaluate erectile dysfunction (ED) recovery after robot-assisted radical prostatectomy (RARP). METHODS: We assessed 144 patients (group with toggling, n = 72; group without toggling, n = 72) who underwent RARP with bilateral NVB sparing using propensity score matching. Inclusion criteria were ≥ 1 year follow-up and preoperative potency as per the Sexual Health Inventory for Men (SHIM) questionnaire (≥ 17 points). Recovery of ED after RARP was defined as return to baseline sexual function or self-assessment regarding successful intercourse. The subjective surgeon's nerve sparing (SNS) score and tunneling success rates were used to evaluate surgical facilitation. The recovery rate of ED between the groups was analyzed using Kaplan-Meier analysis. RESULTS: A better ED recovery trend was confirmed according to the SNS score (R² = 0.142, P = 0.004). In the analysis of NVB sparing ease, the toggling group showed higher SNS scores (on right/left side: P = 0.011 and < 0.001, respectively) and overall tunneling success rates (87% vs. 74%, P = 0.001) than the group without toggling. Overall, ED recovery rates were 82% (59/72) and 75% (54/72) in the groups with and without toggling, respectively, at the 1-year follow-up (P = 0.047), and the toggling group showed a faster ED recovery rate at 3 months (47% vs. 35%, P = 0.013). In a specific analysis of the potent cohort (< 60 years, bilateral full NVB spared, SHIM score ≥ 22), the ED recovery rate reached 87% (14/16) in the toggling group. CONCLUSION: The retrograde early release with the toggling technique improves the facilitation of NVB sparing, leading to improved ED recovery.

A Predictive Preoperative and Postoperative Nomogram for Postoperative Potency Recovery after Robot-Assisted Radical Prostatectomy.

PURPOSE: Prediction of potency recovery following robot-assisted radical prostatectomy (RARP) is useful for better patient counseling and postoperative treatment strategies. In this study we propose a preoperative and postoperative nomogram to predict postoperative potency recovery following RARP. MATERIALS AND METHODS: Patients from development set (6,502) were selected to develop the nomograms, and patients in validation set (2,706) were used for validation. Cox regression models were fitted on the development cohort to predict potency recovery after RARP using as prognostic factors the covariates selected. Two nomograms were drawn using the regression coefficients of the preoperative and postoperative Cox models. RESULTS: The discrimination ability of the preoperative model was evaluated on the development cohort using the receiver operator curves estimated at 3, 6, 12 and 24 months. The AUC at these time points was 0.726, 0.734, 0.754, and 0.778, respectively. The areas under the curve of the postoperative model at 3, 6, 12 and 24 months were 0.746, 0.756 and 0.777, and 0.801, respectively. Preoperative and postoperative predictive models were validated using a separate set of 2,706 patients. The AUCs of the preoperative model at 3, 6, 12 and 24 months were 0.789, 0.772, 0.768, and 0.778, respectively. The ROC curves of the postoperative model at 3, 6, 12 and 24 months with AUCs of 0.807, 0.797, 0.793 and 0.798, respectively. Along with age and preoperative sexual function, nerve-sparing technique determines the potency outcomes justifying better AUC for postoperative model vs the preoperative model. CONCLUSIONS: The above nomograms help us to predict with good accuracy the probability of potency recovery within 3, 6, 12 and 24 months following surgery taking into consideration preoperative and postoperative factors. This is a novel tool for the care giver to predict realistic expectation of potency outcomes to the patients, while preoperative and immediate postoperative counseling.

Trends in clinical and oncological outcomes of robot-assisted radical prostatectomy before and after the 2012 US Preventive Services Task Force recommendation against PSA screening: a decade of experience.

OBJECTIVE: To assess the influence of the 2012 US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen (PSA)-based screening on oncological and functional outcomes following robot-assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: We retrospectively analysed patients who underwent RALP between 2008 and 2018 with a minimum of 12-month follow-up from a prospectively collected institutional review board-approved database. The impact of the USPSTF recommendation against PSA screening on our surgical outcomes was assessed using a logistic regression model using two groups comprising patients treated before/after the USPSTF statement and indicating time trends for each successive year. RESULTS: The mean preoperative PSA increased from 6.0 to 7.4 ng/mL after the USPSTF recommendation. We detected statistically significant time-trend changes after 2012, including an increase in the positive slope of Gleason ≥3 + 4 or ≥pT3 disease. We detected a fall in bilateral full nerve-sparing and an increase in partial nerve-sparing. The total positive surgical margin (PSM) rate increased after the USPSTF recommendation; however, PSM rates pertinent to each pathological stage did not change significantly after 2012. There was a significant negative trend change in the postoperative 12-month continence and potency rates, indicating a breakpoint in functional outcomes after 2012. We detected a 1.7-fold increase in 12-month biochemical recurrence (BCR) rates. The 12-month BCR, potency and continence rates were maintained in young (<55 years) patients with a Sexual Health Inventory for Men score >22 and low-volume disease. CONCLUSION: Since the USPSTF's recommendation in 2012, we have seen a significant increase in the incidence of high-risk disease that has forced us to modify our approach to the procedure and the grade of nerve-sparing used, leading to a wider resection, in order to reduce PSMs. This has led to a decrease in postoperative functional recovery. Patients with favourable characteristics had good outcomes before and after the USPSTF's recommendation, implying that the quality of surgery did not change over time.

A novel tool for predicting extracapsular extension during graded partial nerve sparing in radical prostatectomy.

OBJECTIVES: To create a statistical tool for the estimation of extracapsular extension (ECE) level of prostate cancer and determine the nerve-sparing (NS) approach that can be safely performed during radical prostatectomy (RP). PATIENTS AND METHODS: A total of 11 794 lobes, from 6 360 patients who underwent robot-assisted RP between 2008 and 2016 were evaluated. Clinicopathological features were included in a statistical algorithm for the prediction of the maximum ECE width. Five multivariable logistic models were estimated for: presence of ECE and ECE width of >1, >2, >3, and >4 mm. A five-zone decision rule based on a lower and upper threshold is proposed. Using a graphical interface, surgeons can view patient's pre-treatment characteristics and a curve showing the estimated probabilities for ECE amount together with the areas identified by the decision rule. RESULTS: Of the 6 360 patients, 1 803 (28.4%) were affected by non-organ-confined disease. ECE was present in 1 351 lobes (11.4%) and extended beyond the capsule for >1, >2, >3, and >4 mm in 498 (4.2%), 261 (2.2%), 148 (1.3%), 99 (0.8%) cases, respectively. ECE width was up to 15 mm (interquartile range 1.00-2.00). The five logistic models showed good predictive performance, the area under the receiver operating characteristic curve was: 0.81 for ECE, and 0.84, 0.85, 0.88, and 0.90 for ECE width of >1, >2, >3, and >4 mm, respectively. CONCLUSION: This novel tool predicts with good accuracy the presence and amount of ECE. Furthermore, the graphical interface available at www.prece.it can support surgeons in patient counselling and preoperative planning.

Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis.

To evaluate the influence of posterior musculofascial plate reconstruction (PR) on early return of continence after radical prostatectomy (RP); an updated systematic review of the literature. A systematic review of the literature was performed in June 2015, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and searching Medline, Embase, Scopus and Web of Science databases. We searched the terms posterior reconstruction prostatectomy, double layer anastomosis prostatectomy across the 'Title' and 'Abstract' fields of the records, with the following limits: humans, gender (male), and language (English). The authors reviewed the records to identify studies comparing cohorts of patients who underwent RP with or without restoration of the posterior aspect of the rhabdosphincter. A meta-analysis of the risk ratios estimated using data from the selected studies was performed. In all, 21 studies were identified, including three randomised controlled trials. The overall analysis of comparative studies showed that PR improved early continence recovery at 3-7, 30, and 90 days after catheter removal, while the continence rate at 180 days was statistically but not clinically affected. Statistically significantly lower anastomotic leakage rates were described after PR. There were no significant differences for positive surgical margins rates or for complications such as acute urinary retention and bladder neck stricture. The analysis confirms the benefits at 30 days after catheter removal already discussed in the review published in 2012, but also shows a significant advantage in terms of urinary continence recovery in the first 90 days. A multicentre prospective randomised controlled trial is currently being conducted in several institutions around the world to better assess the effectiveness of PR in facilitating an earlier recovery of postoperative urinary continence.

Continence outcomes of robot-assisted radical prostatectomy in patients with adverse urinary continence risk factors.

OBJECTIVE: To analyse the continence outcomes of robot-assisted radical prostatectomy (RARP) in suboptimal patients that have challenging continence recovery factors such as enlarged prostates, elderly patients, higher body mass index (BMI), salvage prostatectomy, and bladder neck procedures before RARP. PATIENTS AND METHODS: From January 2008 through November 2012, 4,023 patients underwent RARP by a single surgeon at our institution. Retrospective analysis of prospectively collected data identified 3,362 men who had minimum of 1-year follow-up. This cohort of patients was stratified into six groups: Group I, aged ≥70 years (451 patients); Group II, BMI ≥35 kg/m(2) (197); Group III, prior bladder neck procedures (103); Group IV, prostate weight ≥80 g (280); and Group V, salvage prostatectomy (41). Group VI consisted of patients (2 447) with none of these risk factors. Continence outcomes at follow-up were analysed for all groups. RESULTS: The continence rate at 1 year and mean (sd) time to continence in different groups were: for patients aged ≥70 years, 85.6% and 3.2 (4.5) months; BMI of ≥35 kg/m(2) , 87.8% and 3.1 (4.5) months; prior bladder neck treatment, 82.4% and 3.4 (4.7) months; prostate weight of ≥80 g, 85.8% and 3.3 (4.4) months; salvage procedures, 51.3% and 6.6 (8.3) months; and in Group VI (none of the risk factors), 95.1% and 2.4 (3.2) months. The continence rate was significantly higher in group VI compared with the salvage group (group V) at the different follow-up intervals (P < 0.001). When compared with the other groups (I-IV), the continence rate, although higher, was not statistically significant at the different intervals in group VI (no risk). The mean time to continence was significantly lower in group VI compared with the other groups (I-V; P < 0.001). CONCLUSIONS: This study has shown that selected risk factors adversely affect the time to return of continence after RARP, yet aside from salvage patients, there was no statistically significant difference demonstrated between the adverse-risk groups included. Patients undergoing salvage RP had significantly lower continence rates at the various intervals compared with the other groups. Patients with the risk factors identified should be counselled concerning expectations for achieving urinary continence.

Does surgeon subjective nerve sparing score predict recovery time of erectile function following robot-assisted radical prostatectomy?

INTRODUCTION: During robot-assisted radical prostatectomy (RARP), the quality of nerve sparing (NS) was usually classified by laterality of NS (none, unilateral, and bilateral) or degree of NS (none, partial, and full). Recently, side-specific NS have been more frequently performed, but previous NS grading system might not reflect the differential NS in each side. AIM: Herein, we assessed whether a subjective NS score (NSS) incorporating both degree of NS and NS laterality can predict the time to potency recovery following RARP. METHODS: Data were analyzed from 1,898 patients who had left and right neurovascular bundle sparing quality scores and at least one year of follow-up after RARP was performed between January 2008 and October 2011. MAIN OUTCOME MEASURES: Cox proportional hazard method analyses were used to determine predictive factors for early recovery. Multivariate linear regression models were used to assess subjective NSS in an effort to predict time to potency recovery. Subjective NSSs were compared to a model based on the three grades according to laterality and degree. RESULTS: Time to potency recovery showed a statistically significant difference in favor of higher NSS by the Cox proportional hazard regression analysis (NSS 0 vs. NSS 5-6, 7-8, and 9-10; P < 0.01). The regression model indicated that the statistical significance of the subjective NSS covering the differential NS is not different from that of the conventional three-grade scales, while it has a higher R(2). The regression equation with subjective NSS was as follows: Log (Time) = 5.163 - (0.035 × SHIM Score) + 0.028 Age - (0.101 × Subjective NSS). CONCLUSION: The subjective NSS can reflect NS degree for each side based on the visual cues. Regression model can be used to help inform the patient about the time to postoperative potency regain, which is an important patient concern following RARP.

Current status of robotic simulators in acquisition of robotic surgical skills.

PURPOSE OF REVIEW: This article provides an overview of the current status of simulator systems in robotic surgery training curriculum, focusing on available simulators for training, their comparison, new technologies introduced in simulation focusing on concepts of training along with existing challenges and future perspectives of simulator training in robotic surgery. RECENT FINDINGS: The different virtual reality simulators available in the market like dVSS, dVT, RoSS, ProMIS and SEP have shown face, content and construct validity in robotic skills training for novices outside the operating room. Recently, augmented reality simulators like HoST, Maestro AR and RobotiX Mentor have been introduced in robotic training providing a more realistic operating environment, emphasizing more on procedure-specific robotic training . Further, the Xperience Team Trainer, which provides training to console surgeon and bed-side assistant simultaneously, has been recently introduced to emphasize the importance of teamwork and proper coordination. SUMMARY: Simulator training holds an important place in current robotic training curriculum of future robotic surgeons. There is a need for more procedure-specific augmented reality simulator training, utilizing advancements in computing and graphical capabilities for new innovations in simulator technology. Further studies are required to establish its cost-benefit ratio along with concurrent and predictive validity.

Elbow hemiarthroplasty using a "triceps-on" approach for the management of acute distal humeral fractures.

BACKGROUND: Total elbow arthroplasty is an established option for the primary treatment of acute distal humeral fractures, but there are sparse data regarding elbow hemiarthroplasty (EHA) as an alternative. We present the outcome of EHA performed with a modular anatomic prosthesis and a "triceps-on" surgical technique. METHODS: Eighteen consecutive patients underwent EHA for an acute fracture. Two patients died, leaving a study group of 16 patients with minimum 2-year follow-up. Clinical evaluation included range of motion; Mayo Elbow Performance Score; Quick Disabilities of the Arm, Shoulder, and Hand score; and Oxford Elbow Score. Radiographic assessment looked at alignment, evidence of loosening, ulnar and radial head wear, heterotopic ossification, and whether healing of the condyles had occurred. RESULTS: Mean follow-up was 35 months (24-79 months). The mean scores were as follows: Mayo Elbow Performance Score, 89.6; shortened Disabilities of the Arm, Shoulder, and Hand score, 11.2; and Oxford Elbow Score, 43.7. The mean flexion and pronation-supination arcs were 116° and 172° respectively. Radial head wear was absent in 13 patients and mild in 3. Ulnar wear was absent in 6 patients, mild in 8, and moderate in 2. Wear was not associated with greater pain or inferior functional scores. There was no sign of aseptic loosening, and complete condylar bone union occurred in 15 elbows. There was 1 complication, a transient ulnar nerve neurapraxia that resolved without intervention. CONCLUSION: EHA with a modular anatomic implant using a triceps-on approach is a reliable technique for the management of acute unreconstructible distal humeral fractures in older patients.

Isolation, development and identification of salt-tolerant bacterial consortium from crude-oil-contaminated soil for degradation of di-azo dye Reactive Blue 220.

The objective of this study was development and characterization of a halophilic bacterial consortium for rapid decolorization and degradation of a wide range of dyes and their mixtures. The 16S rRNA gene analysis of developed halophilic consortium VN.1 showed that the bacterial consortium contained six bacterial strains, which were identified as Pseudomonas fluorescens HM480360, Enterobacter aerogenes HM480361, Shewanella sp. HM589853, Arthrobacter nicotianae HM480363, Bacillus beijingensis HM480362 and Pseudomonas aeruginosa JQ659549. Halophilic consortium VN.1 was able to decolorize up to 2,500 mg/L RB220 with >85% chemical oxygen demand (COD) reduction under static condition at 30 °C and pH 8.0 in the presence of 7% NaCl. VN.1 also exhibited more than 85% COD reduction with >25 mg/(L h) rate of decolorization in the case of different reactive dye mixtures. We propose the symmetric cleavage of RB220 using Fourier transform infrared, high-performance liquid chromatography (HPLC), nuclear magnetic resonance and gas chromatography-mass spectrometry analysis, and confirmed the formation of sodium-4-aminobenzenesulfonate, sodium-6-aminonepthalenesulfonate, and sodiumbenzene/nepthalenesulfonate. Toxicity studies confirm that the biodegraded products of RB220 effluent stimulate the growth of plants as well as the bacterial community responsible for soil fertility.