Transitioning from Da Vinci Si to Xi: assessing surgical outcomes at a high-volume robotic center.

PURPOSE: In the emerging field of robotics, only few studies investigated the transition between different robotic platforms in terms of surgical outcomes. We aimed at assessing surgical outcomes of patients receiving robot-assisted radical prostatectomy (RARP) and robot-assisted partial nephrectomy (RAPN) at a high-volume robotic center during the transition from Si to Xi Da Vinci surgical systems. METHODS: We analyzed data of 1884 patients undergoing RARP (n = 1437, 76%) and RAPN (n = 447, 24%) at OLV hospital (Aalst, Belgium) between 2011 and 2021. For both procedures, we assessed operative time, estimated blood loss, length of stay, and positive surgical margins. For RARP, we investigated length of catheterization and PSA persistence after surgery, whereas warm ischemia time, clampless surgery, and acute kidney injury (AKI) were assessed for RAPN. Multivariable analyses (MVA) investigated the association between robotic platform (Si vs. Xi) and surgical outcomes after adjustment for patient- and tumor-related factors. RESULTS: A total of 975 (68%) and 462 (32%) patients underwent RARP performed with the Si vs. Xi surgical system, respectively. Baseline characteristics did not differ between the groups. On MVA, we did not find evidence of a difference between the groups with respect to operative time (estimate: 1.07) or estimated blood loss (estimate: 32.39; both p > 0.05). Median (interquartile range [IQR]) length of stay was 6 (3, 6) and 4 (3, 5) days in the Si vs. Xi group, respectively (p < 0.0001). On MVA, men treated with the Xi vs. Si robot had lower odds of PSM (Odds ratio [OR]: 0.58; p = 0.014). A total of 184 (41%) and 263 (59%) patients received RAPN with the Si and Xi robotic system, respectively. Baseline characteristics, including demographics, functional data, and tumor-related features did not differ between the groups. On MVA, operative time was longer in the Xi vs. Si group (estimate: 30.54; p = 0.006). Patients treated with the Xi vs. Si system had higher probability of undergoing a clampless procedure (OR: 2.56; p = 0.001), whereas the risk of AKI did not differ between the groups (OR: 1.25; p = 0.4). On MVA, patients operated with the Xi robot had shorter length of stay as compared to the Si group (estimate: - 0.86; p = 0.003), whereas we did not find evidence of an association between robotic system and PSM (OR: 1.55; p = 0.3). CONCLUSION: We found that the Xi robot allowed for improvements in peri-operative outcomes as compared to the Si platform, with lower rate of positive margins for RARP and higher rate of off-clamp procedures for RAPN. Hospital stay was also shorter for patients operated with the Xi vs. Si robot, especially after robot-assisted partial nephrectomy. Awaiting future investigations-in particular, cost analyses-these results have important implications for patients, surgeons, and healthcare policymakers.

Atlas of Intracorporeal Orthotopic Neobladder Techniques After Robot-assisted Radical Cystectomy and Systematic Review of Clinical Outcomes.

BACKGROUND: Multiple and heterogeneous techniques have been described for orthotopic neobladder (ONB) reconstruction after robot-assisted radical cystectomy. Nonetheless, a systematic assessment of all the available options is lacking. OBJECTIVE: To provide the first comprehensive step-by-step description of all the available techniques for robotic intracorporeal ONB together with individual intraoperative, perioperative and functional outcomes based on a systematic review of the literature. DESIGN, SETTING, AND PARTICIPANTS: We performed a systematic review of the literature, and MEDLINE/PubMed, Embase, Scopus, and Web of Science databases were searched to identify original articles describing different robotic intracorporeal ONB techniques and reporting intra- and perioperative outcomes. Studies were categorized according to ONB type, providing a synthesis of the current evidence. Video material was provided by experts in the field to illustrate the surgical technique of each intracorporeal ONB. SURGICAL PROCEDURE: Nine different ONB types were identified: Studer, Hautmann, Y shape, U shape, Bordeaux, Pyramid, Shell, Florence Robotic Intracorporeal Neobladder, and Padua Ileal Neobladder. MEASUREMENTS: Continuous and categorical variables are presented as mean ± standard deviation and as frequencies and proportions, respectively. RESULTS AND LIMITATIONS: Of 2587 studies identified, 19 met our inclusion criteria. No cohort studies or randomized control trials comparing different neobladder types are available. Available techniques for intracorporeal robotic ONB reconstruction have similar operative time, estimated blood loss, intraoperative complications, and length of stay. Major variability exists concerning postoperative complications and functional outcomes, likely related to reporting bias. CONCLUSIONS: Several techniques are described for intracorporeal ONB during robot-assisted radical cystectomy with comparable perioperative outcomes. We provide the first step-by-step surgical atlas for robot-assisted ONB reconstruction. Further comparative studies are needed to assess any advantage of one technique over others. PATIENT SUMMARY: Patients elected for radical cystectomy should be aware that multiple techniques for robotic orthotopic neobladder are available, but that current evidence does not favor one type over the others.

Holmium Laser Enucleation of the Prostate vs Robot-Assisted Simple Prostatectomy for Lower Urinary Tract Symptoms in Patients with Extremely Large Prostates ≥200 cc: A Comparative Analysis.

Introduction and Objectives: Robot-assisted simple prostatectomy (RASP) and holmium laser enucleation of the prostate (HoLEP) are both well-established, minimally invasive surgical treatment options for lower urinary tract symptoms caused by benign prostatic enlargement. We have reported the first comparative analysis of both techniques in patients with prostates of ≥200 cc. Materials and Methods: Between 2009 and 2020 a total of 53 patients with a prostate volume of ≥200 cc were surgically treated at OLV Hospital Aalst (Belgium): 31 underwent RASP and 22 underwent HoLEP. Preoperative and postoperative assessments included uroflowmetry with maximum urinary flow rate (Qmax) and postvoid residual volume (PVR), as well as the International Prostate Symptom Score (IPSS) and quality of life (IPSS-QoL). The complication rates were evaluated according to the Clavien-Dindo Classification. Results: Patients treated with RASP had significantly larger prostate volumes compared with HoLEP (median 226 cc vs 204.5 cc, p = 0.004). After a median follow-up of 14 months, both groups showed a significant improvement in the maximum flow rate (+10.60 mL/s vs +10.70 mL/s, p = 0.724) and a reduction of the IPSS score (-12.50 vs -9, p = 0.246) as well as improvement of the QoL (-3 vs -3, p = 0.880). Median operative time was similar in both groups (150 minutes vs 132.5 minutes, p = 0.665). The amount of resected tissue was lower in the RASP group (134.5 g vs 180 g, p = 0.029) and there was no significant difference in postoperative prostate-specific antigen (1.2 ng/mL vs 0.8 ng/mL, p = 0.112). Despite a similar median catheterization time (3 days vs 2 days, p = 0.748), the median hospitalization time was shorter in the HoLEP group (4 days vs 3 days, p = 0.052). Complication rates were similar in both groups (32% vs 36%, p = 0.987). Conclusion: Our results suggest similar outcomes for RASP and HoLEP in patients with very large prostates ≥200 cc. These findings will require external validation at other high-volume centers.

Robot-assisted Radical Cystectomy with Orthotopic Neobladder Reconstruction: Techniques and Functional Outcomes in Males.

BACKGROUND: Little is known regarding functional outcomes after robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction. OBJECTIVE: To report on urinary continence (UC) and erectile function (EF) at 12 mo after RARC and ICNB reconstruction and investigate predictors of these outcomes. DESIGN, SETTING, AND PARTICIPANTS: We used data from a multi-institutional database of patients who underwent RARC and ICNB reconstruction for bladder cancer. SURGICAL PROCEDURE: The cystoprostatectomy sensu stricto followed the conventional steps. ICNB reconstruction was performed at the physician's discretion according to the Studer/Wiklund, S pouch, Gaston, vescica ileale Padovana, or Hautmann technique. The techniques are detailed in the video accompanying the article. MEASUREMENTS: The outcomes measured were UC and EF at 12 mo. RESULTS AND LIMITATIONS: A total of 732 male patients were identified with a median age at diagnosis of 64 yr (interquartile range 58-70). The ICNB reconstruction technique was Studer/Wiklund in 74%, S pouch in 1.5%, Gaston in 19%, vescica ileale Padovana in 1.5%, and Hautmann in 4% of cases. The 12-mo UC rate was 86% for daytime and 66% for nighttime continence, including patients who reported the use of a safety pad (20% and 32%, respectively). The 12-mo EF rate was 55%, including men who reported potency with the aid of phosphodiesterase type 5 inhibitors (24%). After adjusting for potential confounders, neobladder type was not associated with UC. Unilateral nerve-sparing (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.88-7.85; p < 0.001) and bilateral nerve-sparing (OR 6.25, 95% CI 3.55-11.0; p < 0.001), were positively associated with EF, whereas age (OR 0.93, 95% CI 0.91-0.95; p < 0.001) and an American Society of Anesthesiologists score of 3 (OR 0.46, 95% CI 0.25-0.89; p < 0.02) were inversely associated with EF. CONCLUSIONS: RARC and ICNB reconstruction are generally associated with good functional outcomes in terms of UC. EF is highly affected by the degree of nerve preservation, age, and comorbidities. PATIENT SUMMARY: We investigated functional outcomes after robot-assisted removal of the bladder in terms of urinary continence and erectile function. We found that, in general, patients have relatively good functional outcomes at 12 months after surgery.

Definition of a Structured Training Curriculum for Robot-assisted Radical Cystectomy with Intracorporeal Ileal Conduit in Male Patients: A Delphi Consensus Study Led by the ERUS Educational Board.

Robot-assisted radical cystectomy (RARC) continues to expand, and several surgeons start training for this complex procedure. This calls for the development of a structured training program, with the aim to improve patient safety during RARC learning curve. A modified Delphi consensus process was started to develop the curriculum structure. An online survey based on the available evidence was delivered to a panel of 28 experts in the field of RARC, selected according to surgical and research experience, and expertise in running training courses. Consensus was defined as ≥80% agreement between the responders. Overall, 96.4% experts completed the survey. The structure of the RARC curriculum was defined as follows: (1) theoretical training; (2) preclinical simulation-based training: 5-d simulation-based activity, using models with increasing complexity (ie, virtual reality, and dry- and wet-laboratory exercises), and nontechnical skills training session; (3) clinical training: modular console activity of at least 6 mo at the host center (a RARC case was divided into 11 steps and steps of similar complexity were grouped into five modules); and (4) final evaluation: blind review of a video-recorded RARC case. This structured training pathway will guide a starting surgeon from the first steps of RARC toward independent completion of a full procedure. Clinical implementation is urgently needed. PATIENT SUMMARY: Robot-assisted radical cystectomy (RARC) is a complex procedure. The first structured training program for RARC was developed with the goal of aiding surgeons to overcome the learning curve of this procedure, improving patients' safety at the same time.

Technical Refinements in Superextended Robot-assisted Radical Prostatectomy for Locally Advanced Prostate Cancer Patients at Multiparametric Magnetic Resonance Imaging.

BACKGROUND: The feasibility and efficacy of robot-assisted radical prostatectomy (RARP) in locally advanced prostate cancer (PCa) patients with iT3 lesion at magnetic resonance imaging (MRI) are currently not explored. OBJECTIVE: To describe our revised RARP technique (ie, superextended RARP [SE-RARP]) for PCa patients with posterior iT3a or iT3b at MRI. DESIGN, SETTING, AND PARTICIPANTS: Data from 89 patients with posterior iT3a or T3b disease who underwent SE-RARP at a single high-volume centre between 2015 and 2018 were analysed. SURGICAL PROCEDURE: RARP was performed using a DaVinci Xi system. The surgical approach provided an inter- or extrafascial RARP where Denonvilliers' fascia and perirectal fat were dissected free and left on the posterior surface of the seminal vesicles. MEASUREMENTS: Perioperative outcomes, and intra- and postoperative complications were assessed. Postoperative outcomes were assessed in patients with complete follow-up data (n = 78). Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values of ≥0.2 ng/ml. Urinary continence (UC) recovery was defined as the use of zero or one safety pad. Kaplan-Meier and multivariable Cox regression models were used. RESULTS AND LIMITATIONS: The median operative time, blood loss, and length of stay were 204 min, 300 ml, and 5 d, respectively. The median bladder catheterisation time was 5 d. Overall, 28%, 28%, and 27% of patients had pathological grade group (GG) 4-5, pT3b, and positive surgical margins (PSMs), respectively. Three patients (3.4%) experienced intraoperative complications. Among patients with available follow-up data (n = 78), 14 (18%) experienced 30-d postoperative complications. The median follow-up was 19 mo. Overall, 11 patients received additional treatment. At 2 yr of follow-up, BCR-free and additional treatment-free survival were 55% and 66%, respectively. Pathological GG 4-5 (hazard ratio [HR] 3.2) and PSM (HR 5.8) were independent predictors of recurrence, as well as of additional treatment use (HR 5.6 for GG 4-5 and 5.2 for PSM). The 1-yr UC recovery was 84%. CONCLUSIONS: We presented our revised RARP technique applicable to patients with posterior iT3a or iT3b at preoperative MRI. This technique is associated with good morbidity and continence recovery rates, and might guarantee biochemical control of the disease and postpone the use of additional treatments in patients with low-grade and negative surgical margins. PATIENT SUMMARY: A revised robot-assisted radical prostatectomy technique applicable to prostate cancer patients with posterior iT3a or iT3b lesion at magnetic resonance imaging was described. This novel technique is feasible and safe in expert hands.

The Effect of Surgical Experience on Perioperative and Oncological Outcomes After Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Evidence from a Referral Centre with Extensive Experience in Robotic Surgery.

BACKGROUND: Evidence on the learning curve for robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is limited. OBJECTIVE: To assess the effect of surgical experience (SE) on perioperative and intermediate-term oncological outcomes in a large contemporary cohort of RARC patients after accounting for the impact of intersurgeon variability. DESIGN, SETTING, AND PARTICIPANTS: The study cohort included 164 patients treated with RARC and ICUD by two surgeons between 2004 and 2017 at a single European referral centre. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: For each patient, SE was defined as the total number of RARCs performed by each surgeon before the patient's operation. The relationship between SE and operative time (OT), lymph node yield (LNY), positive surgical margins (PSMs), Clavien-Dindo grade ≥2 30-d postoperative complication (CD≥2), and oncological outcomes (18-mo recurrence rate) was evaluated in multivariable linear and logistic regression models, clustering at a single-surgeon level. RESULTS AND LIMITATIONS: After adjusting for case mix, SE was associated with shorter OT (p= 0.003), lower probability of postoperative CD≥2 rates (p= 0.01), and lower 18-mo recurrence rates (p= 0.002). Conversely, SE did not predict lower PSM rates (p= 0.3) and higher LNY (p= 0.4). The relationship between SE and OT was nonlinear, with a plateau observed after 50 cases. Conversely, the relationship between SE and CD≥2 and 18-mo recurrence was linear without reaching a plateau after 88 procedures. CONCLUSIONS: SE affects perioperative and oncological outcomes after RARC with ICUD in a linear fashion, and its beneficial effect does not reach a plateau. Conversely, after 50 cases, no further improvement was observed for OT. PATIENT SUMMARY: Robot-assisted radical cystectomy with intracorporeal urinary diversion is a complex surgical procedure with a relatively long learning curve.

The Impact of Surgical Strategy in Robot-assisted Partial Nephrectomy: Is It Beneficial to Treat Anterior Tumours with Transperitoneal Access and Posterior Tumours with Retroperitoneal Access?

Available comparison of transperitoneal robot-assisted partial nephrectomy (tRAPN) and retroperitoneal robot-assisted partial nephrectomy (rRAPN) does not consider tumour's location. The aim of this study was to compare perioperative morbidity, and functional and pathological outcomes after tRAPN and rRAPN, with the specific hypothesis that tRAPN for anterior tumours and rRAPN for posterior tumours might be a beneficial strategy. A large global collaborative dataset of 1169 cT1-2N0M0 patients was used. Propensity score matching, and logistic and linear regression analyses tested the effect of tRAPN versus rRAPN on perioperative outcomes. No differences were observed between rRAPN and tRAPN with respect to complications, operative time, length of stay, ischaemia time, median 1-yr estimated glomerular filtration rate (eGFR), and positive surgical margins (all p>0.05). Median estimated blood loss and postoperative eGFR were 50 versus100ml (p<0.0001) and 82 versus 78ml/min/1.73 m2 (p=0.04) after rRAPN and tRAPN, respectively. At interaction tests, no advantage was observed after tRAPN for anterior tumours and rRAPN for posterior tumours with respect to complications, warm ischaemia time, postoperative eGFR, and positive surgical margins (all p>0.05). The techniques of rRAPN and tRAPN offer equivalent perioperative morbidity, and functional and pathological outcomes, regardless of tumour's location. PATIENT SUMMARY: Robot-assisted partial nephrectomy can be performed with a transperitoneal or a retroperitoneal approach regardless of the specific position of the tumour, with equivalent outcomes for the patient.

The Learning Curve for Robot-assisted Partial Nephrectomy: Impact of Surgical Experience on Perioperative Outcomes.

Robot-assisted partial nephrectomy (RAPN) outcomes might be importantly affected by increasing surgical experience (EXP). The aim of the study is to investigate the effect of EXP on warm ischemia time (WIT), presence of at least one Clavien-Dindo ≥2 postoperative complication (CD ≥ 2), and positive surgical margins (PSMs) to define the learning curve for RAPN. We evaluated 457 consecutive patients diagnosed with a cT1-T2 renal mass were evaluated. EXP was defined as the total number of RAPNs performed by each surgeon before each patient's operation. Median WIT was 14min and the rate of CD ≥ 2 and PSMs was 15% and 4%, respectively. At multivariable regression analyses adjusted for case mix, EXP resulted associated with shorter WIT (p<0.0001) and higher probability of CD ≥ 2-free postoperative course (p=0.001), but not with PSMs (p=0.7). The relationship between EXP and WIT emerged as nonlinear, with a steep slope reduction within the first 100 cases and a plateau observed after 150 cases. Conversely, the relationship between EXP and CD ≥ 2-free course resulted linear, without reaching a plateau, even after 300 cases. Patient summary: Perioperative outcomes after robot-assisted partial nephrectomy (RAPN) are importantly and individually affected by surgeon's experience. After 150 RAPNs, no further improvement is observed with respect to ischemia time, but the learning curve appears endless with respect to complications.

What's new in robotic partial nephrectomy.

OBJECTIVE: Robot assisted partial nephrectomy (RAPN) is a minimally invasive option for patients with small renal masses undergoing partial nephrectomy. In this review we provide an update on the oncological safety and renal functional outcomes following RAPN. We also discuss the novel techniques and technological advances that have contributed to the outcomes of RAPN.  METHODS: A Medline search using the keywords "partial nephrectomy", "robotic partial nephrectomy", "robot assisted partial nephrectomy", "robot assisted laparoscopic partial nephrectomy" and "laparoscopic partial nephrectomy" was conducted to identify original articles, review articles, and editorials on RAPN. RESULTS: A review of the literature suggests that RAPNis emerging as the preferred approach to minimally invasive nephron sparing surgery. RAPN is superior to laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) in terms of perioperative outcomes with equivalent mid-term oncological outcomes. RAPN has proven safety and efficacy even in complex renal tumors with equivalent oncological and functional outcomes. Novel techniques and advances in technology have contributed to the safety and efficacy of RAPN. CONCLUSION: RAPN can be considered to be the gold standard approach to minimally invasive nephronsparing surgery with equivalent oncological and  renal functional outcomes and superior perioperative outcomes when compared to OPN. Newer techniques and developments in robotic technology have contributed to improved outcomes following RAPN.

OBJETIVO: La nefrectomía parcial asistida por robot (NPAR) es una opción mínimamente invasivapara pacientes con masas renales pequeñasintervenidos mediante nefrectomía parcial. En esta revisiónpresentamos una puesta al día sobre la seguridadoncológica y los resultados funcionales después dela NPAR. También discutimos las nuevas técnicas y losavances tecnológicos que han contribuido a los resultadosde la NPAR.MÉTODOS: Se realizó una búsqueda bibliográficapara identificar artículos originales, de revisión y editorialessobre la NPAR, utilizando las palabras clave nefrectomía parcial, nefrectomía parcial robótica, nefrectomíaparcial asistida por robot, nefrectomía parciallaparoscópica asistida por robot y nefrectomía parcial laparoscópica. RESULTADOS: Una revisión de la literatura sugiere quela NPAR está emergiendo como el abordaje preferidode la cirugía conservadora de nefronas mínimamenteinvasiva. La NPAR es superior a la nefrectomía parciallaparoscópica (NPL) y la nefrectomía parcial abierta(NPA) en resultados peroperatorios con resultados oncológicosa medio plazo equivalentes. La NPAR hademostrado seguridad y eficacia, incluso en tumoresrenales complejos, con resultados oncológicos y funcionalesequivalentes. Las técnicas nuevas y los avancestecnológicos han contribuido a la seguridad y eficaciade la NPAR. CONCLUSIONES: La NPAR puede considerarse elabordaje patrón oro de referencia para la cirugía conservadorade nefronas mínimamente invasiva con resultadosoncológicos y funcionales renales equivalentes yresultados peroperatorios superiores en comparacióncon NPA. Las técnicas y desarrollos más nuevos entecnología robótica han contribuido a mejorar los resultados de la NPAR.