A comparative study of peri-operative outcomes for 100 consecutive post-chemotherapy and primary robot-assisted and open retroperitoneal lymph node dissections.

PURPOSE: To describe and compare differences in peri-operative outcomes of robot-assisted (RA-RPLND) and open (O-RPLND) retroperitoneal lymph node dissection performed by a single surgeon where chemotherapy is the standard initial treatment for Stage 2 or greater non-seminomatous germ cell tumour. METHODS: Review of a prospective database of all RA-RPLNDs (28 patients) and O-RPLNDs (72 patients) performed by a single surgeon from 2014 to 2020. Peri-operative outcomes were compared for patients having RA-RPLND to all O-RPLNDs and a matched cohort of patients having O-RPLND (20 patients). Further comparison was performed between all patients in the RA-RPLND group (21 patients) and matched O-RPLND group (18 patients) who had previous chemotherapy. RA-RPLND was performed for patients suitable for a unilateral template dissection. O-RPLND was performed prior to the introduction of RA-RPLND and for patients not suitable for RA-RPLND after its introduction. RESULTS: RA-RPLND showed improved peri-operative outcomes compared to the matched cohort of O-RPLND-median blood loss (50 versus 400 ml, p < 0.00001), operative duration (150 versus 195 min, p = 0.023) length-of-stay (1 versus 5 days, p < 0.00001) and anejaculation (0 versus 4, p = 0.0249). There was no statistical difference in complication rates. RA-RPLND had lower median lymph node yields although not significant (9 versus 13, p = 0.070). These improved peri-operative outcomes were also seen in the post-chemotherapy RA-RPLND versus O-RPLND analysis. There were no tumour recurrences seen in either group with median follow-up of 36 months and 60 months, respectively. CONCLUSIONS: Post-chemotherapy RA-RPLND may have decreased blood loss, operative duration, hospital length-of-stay and anejaculation rates in selected cases and should, therefore, be considered in selected patients. Differences in oncological outcomes require longer term follow-up.

'Trifecta' outcomes of robot-assisted partial nephrectomy in solitary kidney: a Vattikuti Collective Quality Initiative (VCQI) database analysis.

OBJECTIVES: To analyse the outcomes of robot-assisted partial nephrectomy (RAPN) in patients with a solitary kidney in a large multi-institutional database. PATIENTS AND METHODS: In all, 2755 patients in the Vattikuti Collective Quality Initiative database underwent RAPN by 22 surgeons at 14 centres in nine countries. Of these patients, 74 underwent RAPN with a solitary kidney between 2007 and 2016. We retrospectively analysed the functional and oncological outcomes of these 74 patients. A 'trifecta' of outcomes was assessed, with trifecta defined as a warm ischaemia time (WIT) of <20 min, negative surgical margins, and no complications intraoperatively or within 3 months of RAPN. RESULTS: All 74 patients underwent RAPN successfully with one conversion to radical nephrectomy. The median (interquartile range [IQR]) operative time was 180 (142-230) min. Early unclamping was used in 11 (14.9%) patients and zero ischaemia was used in 12 (16.2%). Trifecta outcomes were achieved in 38 of 66 patients (57.6%). The median (IQR) WIT was 15.5 (8.75-20.0) min for the entire cohort. The overall complication rate was 24.1% and the rate of Clavien-Dindo grade ≤II complications was 16.3%. Positive surgical margins were present in four cases (5.4%). The median (IQR) follow-up was 10.5 (2.12-24.0) months. The median drop in estimated glomerular filtration rate at 3 months was 7.0 mL/min/1.72 m2 (11.01%). CONCLUSION: Our findings suggest that RAPN is a safe and effective treatment option for select renal tumours in solitary kidneys in terms of a trifecta of negative surgical margins, WIT of <20 min, and low operative and perioperative morbidity.

Intraoperative Frozen Section of the Prostate Reduces the Risk of Positive Margin Whilst Ensuring Nerve Sparing in Patients with Intermediate and High-Risk Prostate Cancer Undergoing Robotic Radical Prostatectomy: First Reported UK Series.

INTRODUCTION: Nerve sparing during robotic radical prostatectomy (RRP) considerably improves post-operative potency and urinary continence as long as it does not compromise oncological outcome. Excision of the neurovascular bundle (NVB) is often performed in patients with intermediate and high risk prostate cancer to reduce the risk of positive surgical margin raising the risk of urinary incontinence and impotence. We present the first UK series outcomes of such patients who underwent an intra-operative frozen section (IOFS) analysis of the prostate during RRP allowing nerve sparing. PATIENTS AND METHODS: We prospectively analysed the data of 40 patients who underwent an IOFS during RRP at our centre from November 2012 until November 2014. Our IOFS technique involved whole lateral circumferential analysis of the prostate during RRP with the corresponding neurovascular tissue. An intrafascial nerve spare was performed and the specimen was removed intra-operatively via an extension of the 12 mm Autosuture™ camera port without undocking robotic arms. It was then painted by the surgeon and sprayed with "Ink Aid" prior to frozen section analysis. The corresponding NVB was excised if the histopathologist found a positive surgical margin on frozen section. RESULTS: Median time to extract the specimen, wound closure and re-establishment of pneumoperitoneum increased the operative time by 8 min. Median blood loss for IOFS was 130 ± 97 ml vs. 90 ± 72 ml (p = NS). IOFS was not associated with major complications or with blood transfusion. PSM decreased significantly from non-IOFS RRP series of 28.7 to 7.8% (p < 0.05). Intra-operative PSM on the prostate specimen was seen in 8/40 margin analysis (20%) leading to an excision of the contra-lateral nerve bundle. On analysis of the nerve bundle on a paraffin embedded block, 6 nerve bundle matched tumor on the specimen whereas 2 NVB were retrospectively removed unnecessarily in our series. All 40 patients have undetectable PSA at a mean follow up of 21.2 months (SD 7.79). Functional data at 18 months confirms a reduction in the urinary incontinence from 37% in the IOFS group vs 57% in the non-IOFS group (p = NS). IOFS technique has resulted in a significant increase in intravesical nerve sparing in both T2/T3 patients with intermediate and high risk prostate cancer when appropriately counselled and selected (T2 from 100% in the IOFS group versus 67% and T3 from 100% in the IOFS group to 42%) (p < 0.05). CONCLUSION: Introduction of the IOFS analysis during intrafascial nerve spare RRP has reduced PSM and the rate of urinary incontinence.

Effect of Pneumoperitoneum on Renal Function and Physiology in Patients Undergoing Robotic Renal Surgery.

Laparoscopic and minimally-invasive robotic access has transformed the delivery of urological surgery. While associated with numerous desirable outcomes including shorter post-operative stay and faster return to preoperative function, these techniques have also been associated with increased morbidity such as reduced renal blood flow and post-operative renal dysfunction. The mechanisms leading to these renal effects complex and multifactorial, and have not been fully elucidated. However they are likely to include direct effects from raised intra-abdominal pressure, and indirect effects secondary to carbon dioxide absorption, neuroendocrine factors and tissue damage from oxidative stress. This review summarises these factors, and highlights the need for further work in this area, to direct novel therapies and guide alterations in technique with the aim of reducing renal dysfunction post-laparoscopic and robotic surgery.

Robot-Assisted Laparoscopic Bladder Diverticulectomy and Ureteral Re-Implantation for a Diverticulum Containing High Grade Transitional Cell Carcinoma.

We present a case of an 84-year-old man presenting with painless visible hematuria. Further investigation revealed a primary G3pT1 transitional cell carcinoma confined to a bladder diverticulum. In view of bladder-sparing therapy, he underwent a robot-assisted laparoscopic bladder diverticulectomy with ureteral re-implantation. This report demonstrates a minimally invasive approach offering radical treatment without having to recur to partial or radical cystectomy. We discuss the operative steps, the significance of this case with a review of the literature, and the future potential this may represent for the treatment of tumor-containing bladder diverticula.

Robotic Partial Cystectomy for Primary Urachal Adenocarcinoma of the Urinary Bladder.

We present the largest reported consecutive series on robotic partial cystectomy in the management of patients with primary urachal adenocarcinoma. Eight patients with primary urachal adenocarcinoma of the urinary bladder underwent a robotic partial cystectomy. The mean operative time, including trocar placement as well as robotic docking and closure was 184 minutes (range 130-240 minutes). The mean console time was 120 minutes (range 70-170 minutes). The mean estimated blood loss was 50 ml. There were no conversions to open surgery. The mean hospital stay was 4 days (range 3-7 days). Drain removal was performed at postoperative day 2.5 (range 2-3 days). Each patient underwent postoperative cystography on day 10 postoperatively and no patients had evidence of extravasation. There were no major complications. Histological analysis of all tumors confirmed primary urachal adenocarcinoma of the urinary bladder. There were no positive surgical margins. At a mean follow up of 32 months none of the patients have had a disease recurrence with any evidence of disease recurrence. Our initial data indicates that with robotic partial cystectomy for primary urachal adenocarcinoma of the urinary bladder is a safe surgical and oncological procedure. However, longer follow up and larger patient numbers are required to validate this further.

Evolving role of positron emission tomography (PET) in urological malignancy.

We present a review on the increasing indications for the use of positron emission tomography (PET) in uro-oncology. In this review we describe the details of the different types of PET scans, indications for requesting PET scans in specific urological malignancy and the interpretation of the results.

The physiologic and anesthetic considerations in elderly patients undergoing robotic renal surgery.

A number of patients are diagnosed with renal malignancies incidentally worldwide. Once a diagnosis of a renal malignancy is established, after a careful evaluation, patients can be offered a robotic nephrectomy or partial nephrectomy. We present a review of the physiologic and anesthetic considerations in elderly patients who are being considered for robotic renal surgery.

Robotic versus traditional laparoscopic partial nephrectomy: comparison of outcomes with a transition of techniques.

We aimed to evaluate the effect of a transition from laparoscopic partial nephrectomy (LPN) to robotic-assisted laparoscopic partial nephrectomy (RALPN) on peri-operative and oncological patient outcomes. We present the results of the last 50 LPN (group 1) compared with our first 50 RALPN (group 2). The peri-operative data was evaluated using appropriate comparison tests. The parameters compared included operative times, warm ischaemia time (WIT), estimated blood loss (EBL), complications using the Clavien-Dindo (CD) grading system and oncological outcomes including positive surgical margin (PSM) rates. Patients in group 1 (n = 50) and group 2 (n = 50) had comparable pre-operative RENAL scores, ASA scores and tumour size characteristics. Ninety-four percent of the patients in group 1 underwent retroperitoneal LPN while 96 % of patients in group 2 underwent transperitoneal RALP. The mean total operative time in groups 1 and 2 was 163 versus 195 min, respectively (p = 0.003), and EBL was 294 versus 187 ml (p < 0.001). There was no statistically significant difference in WIT between groups 1 and 2 (24.7 and 21.8 min, respectively, p = 0.18). Post-operative histology was comparable in the two groups and the PSM rate was 8 versus 4 % (p = 0.58). The CD major complication rate was 16 % in group 1 versus 4 % in group 2 (p < 0.001). In our series, RALPN appears to have a longer initial total operative time than LPN; however, this reduces after the first 20 cases. RALP has a significant reduction in EBL and post-operative major complication rates, including immediate peri-operative complication rates such as the risk of acute haemorrhage or urinoma. Our data indicates that it is safe to change from LPN to RALPN with no compromise in patient safety or oncological outcomes.

Robotic Intracorporeal Ileal Conduit Formation: Initial Experience from a Single UK Centre.

Objectives. To describe our technique of robotic intracorporeal ileal conduit formation (RICIC) during robotic-assisted radical cystectomy (RARC). To report our initial results of this new procedure. Patients and Methods. Seven male and one female patients underwent RARC with RICIC over a six-month period. Demographic, operative, and outcome data was collected prospectively. Median patient age was 75 years (range 62-78 years). Median followup was 9 months (range 7-14 months). Results. RARC with RICIC was performed successfully in all eight patients. The median total operating time was 360 minutes (range 310-440 minutes) with a median blood loss of 225 mL (range 50-1000 mL). The median length of stay was nine days (range 6-34 days). Four patients (50%) were discharged within seven days. Four patients (50%) experienced one or more complications. This included two Clavien I complications, two Clavien II complications, and two Clavien III complications. Two patients (25%) required transfusion of two units each. To date, there have been no complications associated with the ileal conduit. Conclusion. Whilst being technically challenging, this procedure is safe, feasible, and reproducible. Patients who avoid complication show potential for rapid recovery and early discharge.

"The Lister Technique": a new technique for the management of the distal ureter during radical robotic nephroureterectomy.

We describe "The Lister Technique"-a new 3 step procedure developed in our department for robotic assisted laparoscopic nephroureterectomy (RANU). Our new technique facilitates the complete excision of the whole ureter including ureteric orifice and reduces this risk of tumour spillage from the distal ureter without the need for bivalving the bladder. Our initial data indicates that the technique is associated with reduction in bladder recurrence post-operatively in comparison to current published series. Longer follow up and larger patient numbers are required to validate these results further.

Developing a robotic prostatectomy service and a robotic fellowship programme - defining the learning curve.

INTRODUCTION: Robotic radical prostatectomy (RRP) is an established treatment for prostate cancer in selected centres with appropriate expertise. We studied our single-centre experience of developing a RRP service and subsequent training of 2 additional surgeons by the initial surgeon and the introduction of United Kingdom's first nationally accredited robotic fellowship training programme. We assessed the learning curve of the 3 surgeons with regard to peri-operative outcomes and oncological results. PATIENTS AND METHODS: Three hundred consecutive patients underwent RRP between November 2008 and August 2012. Patients were divided into 3 equal groups (Group 1, case 1-100; Group 2, case 101-200; and Group 3, case 201-300). Age, ASA score, preoperative co-morbidities and indications for laparoscopic radical prostatectomy were comparable for all 3 patient groups. Peri-operative and oncological outcomes were compared across all 3 groups to assess the impact of the learning curve for laparoscopic radical prostatectomy. All surgical complications were classified using the Clavien-Dindo system. RESULTS: The mean age was 60.7 years (range 41-74). There was a significant reduction in the mean console time (p < 0.001), operating time (p < 0.001), mean length of hospital stay (p < 0.001) and duration of catheter (p < 0.001) between the 3 groups as the series progressed. The two most important factors predictive of positive surgical margins (PSM) at RRP were the initial prostate specific antigen (PSA) and tumor stage at diagnosis. The overall PSM rate was 26.7%. For T2/T3 tumors the incidence of PSM reduced as the series progressed (Group 1-22%, Group 2-32% and Group 3-26%). The incidence of major complications i.e. grade Clavien-Dindo system score ≤ III was 2% (6/300). CONCLUSION: RRP is a safe procedure with low morbidity. As surgeons progress through the learning curve peri-operative parameters and oncological outcomes improve. This learning curve is not affected by the introduction of a fellowship-training programme. Using a carefully structured mentored approach, RRP can be safely introduced as a new procedure without compromising patient outcomes.