A Retrospective Analysis of 83 Patients with Testicular Mass Who Underwent Testis-Sparing Surgery: The Eurasian Uro-oncology Association Multicenter Study.

INTRODUCTION: Herein, we analyzed the histopathological, oncological and functional outcomes of testis-sparing surgery (TSS) in patients with distinct risk for testicular cancer. METHODS: This is a multicenter retrospective study on consecutive patients who underwent TSS. Patients were categorized in high- or low-risk testicular germ cell tumor (TGCT) according to the presence/absence of features compatible with testicular dysgenesis syndrome. Histology was categorized per size and risk groups. RESULTS: TSS was performed in 83 patients (86 tumors) of them, 27 in the high-risk group. Fifty-nine patients had a non-tumoral contralateral testis present. Sixty masses and 26 masses were benign and TGCTs, respectively. No statistical differences were observed in mean age (30.9 ± 10.32 years), pathological tumor size (14.67 ± 6.7 mm) between risk groups or between benign and malignant tumors (p = 0.608). When categorized per risk groups, 22 (73.3%) and 4 (7.1%) of the TSS specimens were malignant in the high- and low-risk patient groups, respectively. Univariate analysis showed that the only independent variable significantly related to malignant outcome was previous history of TGCT. During a mean follow-up of 25.5 ± 22.7 months, no patient developed systemic disease. Local recurrence was detected in 5 patients and received radical orchiectomy. Postoperative testosterone levels remained normal in 88% of those patients with normal preoperative level. No erectile dysfunction was reported in patients with benign lesions. CONCLUSION: TSS is a safe and feasible approach with adequate cancer control, and preservation of sexual function is possible in 2/3 of patients harboring malignancy. Incidence of TGCT varies extremely between patients at high and low risk for TGCT requiring a careful consideration and counseling.

Comparison of Tumor Enucleation and Standard Partial Nephrectomy According to Trifecta Outcomes: A Multicenter Study by the Turkish Academy of Urology, Uro-Oncology Working Group.

INTRODUCTION: We aimed to evaluate the impact of the resection technique (tumor enucleation (TE) or standard partial nephrectomy (SPN)) on trifecta outcomes in patients having undergone partial nephrectomy (PN). MATERIALS AND METHODS: We retrospectively analyzed the clinical and pathologic parameters in patients with localized renal cell carcinoma (pT1-2N0M0) who had undergone PN between January 2001-December 2018 at one of 15 different tertiary referral centers. Multivariable logistic regression analysis was applied to investigate independent predictors of trifecta failure, decreased postoperative renal functions (decreased estimated glomerular filtration rate (eGFR) > 10%), perioperative complications (Clavien-Dindo > 1), and positive surgical margins. RESULTS: A total of 1070 patients with a mean age 56.11 ± 11.88 years were included in our study. PN was performed with TE in 848 (79.25%) and SPN in 222 (20.75%) patients. Trifecta failure rate was 56.2% for TE and 64.4% for SPN (p = 0.028). On multivariable analysis, TE was associated with less trifecta failure (p = 0.025) and eGFR decrease >10% rates (p = 0.024). On the other hand, there was no statistically significant difference between TE and SPN according to positive surgical margins (p = 0.450) and complication > Clavien-Dindo grade 1 (p = 0.888) rates. The only independent predictive factor for complications > Clavien-Dindo 1 was the Charlson comorbidity index (CCI) (p = 0.001). CONCLUSION: TE is associated with less trifecta failure than SPN. This result is mainly due to better preservation of renal function with TE.

Retzius-sparing robot-assisted radical prostatectomy: early learning curve experience in three continents.

OBJECTIVE: To assess the effect of surgical experience on peri-operative, functional and oncological outcomes during the first 50 Retzius-sparing robot-assisted radical prostatectomy (RsRARP) cases performed by surgeons naïve to this novel approach. MATERIALS AND METHODS: We retrospectively evaluated the initial cases operated by 14 surgeons in 12 different international centres. Pre-, peri- and postoperative features of the first 50 patients operated by each surgeon in all the participating centres were collected. The effect of surgical experience on peri-operative, functional and oncological outcomes was firstly evaluated after stratification by level of surgical experience (initial [≤25 cases] and expert [>25 cases]) and after using locally weighted scatterplot smoothing to graphically explore the relationship between surgical experience and the outcomes of interest. RESULTS: We evaluated 626 patients. The median follow-up was 13 months in the initial group and 9 months in the expert group (P = 0.002). Preoperative features overlapped between the two groups. Shorter console time (140 vs 120 min; P = 0.001) and a trend towards lower complications rates (13 vs 5.5%; P = 0.038) were observed in the expert group. The relationship between surgical experience and console time, immediate urinary continence recovery and Clavien-Dindo grade ≥2 complications was linear, without reaching a plateau, after 50 cases. Conversely, a non-linear relationship was observed between surgical experience and positive surgical margins (PSMs). CONCLUSIONS: In this first report of a multicentre experience of RsRARP during the learning curve, we found that console time, immediate urinary continence recovery and postoperative complications are optimal from the beginning and further quickly improve during the learning process, while PSM rates did not clearly improve over the first 50 cases.

Comparison of surgical, oncological, and functional outcomes of robot-assisted and laparoscopic radical prostatectomy in patients with prostate cancer.

OBJECTIVE: To compare the oncological and functional outcomes of robot-assisted radical prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP). MATERIAL AND METHODS: We compared patients who underwent the RARP (n=778) and LRP (n=48) techniques for prostate cancer between January 2008 and July 2017 in our clinic. Patient demographics, preoperative and postoperative data, pathologic evaluation, continence, and potency rates were collected and analyzed retrospectively. RESULTS: The preoperative and demographic data of the patients we included in our study were similar. The mean operation time estimated blood loss, length of hospitalization, and catheterization time were significantly shorter in the RARP group. The statistical analysis was in favor of robotic prostatectomy in the terms of the mean length of hospitalization, catheterization time, and early (<30 days) and intermediate (31-90 days) complications. Positive surgical margins and biochemical recurrence rates, and recovery of continence and erectile function, were similar in both groups. CONCLUSION: RARP and LRP in organ-confined prostate cancer are safe and effective methods. Robotic prostatectomy has a shorter operative time, length of hospitalization, catheterization time, and lower early and late complication rates.

Is testis-sparing surgery safe in small testicular masses? Results of a multicentre study.

INTRODUCTION: Our goal was to evaluate benign and malignant lesions and testicular intraepithelial neoplasia (TIN) in the neighbouring normal-appearing testis tissue in men who underwent radical orchiectomy for testicular mass with a pathologic tumour size of ≤3cm. METHODS: In this retrospective, multicentre study, data of 252 patients from 11 different institutions were included. Patients were divided into three groups based on tumour size: Group 1 (0-1 cm; n=35), Group 2 (1.1-2cm; n=99), and Group 3 (2.1-3 cm; n=118). Benign lesions and TIN were sought in the neighbouring testicular tissue and compared between groups. RESULTS: Mean patient age was 32.3 years. Benign lesions were reported in 54.3%, 33.3%, and 14.4% of Groups 1, 2, and 3, respectively (p<0.05 between groups). TIN was detected in 20%, 42.4%, and 41.5% of Groups 1, 2, and 3, respectively (p<0.05 for Group 1 vs. Groups 2 and 3; p>0.05 for Groups 2 vs. 3). Multifocality was detected in 8.6%, 4%, and 0% of Groups 1, 2, and 3, respectively (p<0.05 for both Group 1 vs. Group 3 and for Group 2 vs. Group 3; p>0.05 for Group 1 vs. Group 2). A tumour cutoff size of 1.5 cm was found to be significant for detecting benign tumour. TIN and multifocality rates were similar in patients with a tumour size of ≤1.5 vs. >1.5 cm (p>0.05). CONCLUSIONS: Benign lesions and TIN in the neighbouring testis were significantly decreased and multifocality was increased in patients with a tumour mass size of ≤1 cm. Testis-sparing surgery should be performed with caution and a safety rim of normal tissue should also be excised.

Robot-assisted radical prostatectomy in low- and high-risk prostate cancer patients.

OBJECTIVE: To evaluate the benefit of robot-assisted radical prostatectomy (RARP) in the low-risk prostate cancer (PCa) patients suitable for active surveillance and in the high-risk PCa patients who would be considered for alternative treatments such as radiotherapy (RT) and androgen deprivation therapy (ADT) instead of radical prostatectomy. MATERIAL AND METHODS: Of 548 patients, who underwent RARP, 298 PCa patients (258 low-risk and 40 high-risk) with a mean of 3.6 years follow-up, were included into this study. Oncological outcomes were compared separately in low- and high-risk PCa patients. RESULTS: The pathologic Gleason scores were ≥7 in 73 (28%), and 68 (26%) patients had a pathologic stage of T3, 29 (11%) patients had a positive surgical margin (PSM), and 20 (7%) patients had biochemical recurrence (BCR) in the first year follow-up in the low-risk group. Of 258 low-risk PCa patients, a total of 93 (36%) patients had not either BCR, pathologic Gleason score ≥7, or ≥pT3 disease with PSM. In the high-risk group, the pathologic stage was pT2 in 14 (35%) patients and 29 (72%) patients had no biochemical recurrence in the follow-up of these high-risk PCa patients. Of 40 high-risk PCa patients, in a total of 25 (62.5%) patients ≥pT3b disease, BCR, pT3a disease with PSM were not detected. CONCLUSION: Approximately two thirds of high-risk PCa patients benefit from RARP without additional RT or ADT. Besides, more than one third of low-risk PCa patients who fit active surveillance criteria would have unfavorable results.

Long-term functional results of aspiration and sclerotherapy with ethanol in patients with autosomal dominant polycystic kidney disease: a non-randomized pilot clinical study.

PURPOSE: To evaluate the long-term effect of aspiration and sclerotherapy treatment on the pain control, blood pressure regulation, and quality of life (QoL) in patients with autosomal dominant polycystic disease (ADPKD). METHODS: Twenty-five ADPKD patients with a total of 32 dominant cysts were treated with ultrasound guidance percutaneous aspiration and 96% ethanol injection, between 2002 and 2014. Twenty-one dominant cysts of 16 patients who had a minimum of 10-year follow-up were included in this study. The level of pain [visual analog score (VAS)], narcotic usage, blood pressure and serum creatinine level, QoL questionnaire, and radiological dominant cyst size was evaluated before and after procedure, retrospectively. RESULTS: The mean dominant cyst size was even smaller after follow-up of 10 years. Mean dominant cyst size was 7.2 ± 2.3 cm before the procedure and 0.9 ± 0.9 and 3.3 ± 1.2 cm after the one- and 10-year follow-ups, respectively (p < 0.05). VAS and QoL scores were improved after 10 years of follow-up. There was no relation between cyst size and VAS score as well as QoL questionnaire score. End-stage renal disease occurred in 50%, and there was no significant improvement in blood pressure of these patients. CONCLUSIONS: Aspiration and sclerotherapy with ethanol is a minimal-invasive, safe, and inexpensive outpatient treatment method with acceptable short- and long-term results in ADPKD patients. Aspiration and sclerotherapy with ethanol can be an option for patients with ADPKD.

Effectiveness of acupuncture on chronic prostatitis-chronic pelvic pain syndrome category IIIB patients: a prospective, randomized, nonblinded, clinical trial.

OBJECTIVE: To compare the acupuncture treatment and the medical treatment with antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs) on pain control, urinary symptoms, and quality of life of category IIIB chronic prostatitis-chronic pelvic pain syndrome (CP-CPPS). METHODS: From November 2008 to May 2009, 54 male patients with category IIIB CP-CPPS were randomly divided into 2 groups: the medical treatment group (group 1, n = 28) and the acupuncture treatment group (group 2, n = 26). Group 1 took levofloxacin 500 mg daily and ibuprofen 200 mg twice a day for 6 weeks. In the acupuncture group (group 2), bilateral BL32 (Ciliao) and BL33 (Zhongliao) acupoints were used to stimulate the sacral nerve using an electrical pulse generator, twice a week for 7 weeks. The change in National Institutes of Health Chronic Prostatitis Symptom Index scores from the baseline to the end of the treatment was observed. RESULTS: The mean follow-up was 28 weeks from the baseline (range, 20-43 weeks). In acupuncture group, reduction of pain, urinary symptoms, quality of life, and total National Institutes of Health Chronic Prostatitis Symptom Index score was higher compared with the medical group. CONCLUSION: However the treatment of CP-CPPS is challenging and difficult for the urologists. This clinical study showed that the acupuncture treatment is a safe and effective treatment of category IIIB CP-CPPS.

Comparison of surgical, functional, and oncological outcomes of open and robot-assisted partial nephrectomy.

BACKGROUND: We aimed to compare the surgical, oncological, and functional outcomes of robot-assisted partial nephrectomy (RAPN) with open partial nephrectomy (OPN) in the management of small renal masses. MATERIALS AND METHODS: Between 2009 and 2013, a total of 46 RAPN patients and 20 OPN patients was included in this study. Patients' demographics, mean operative time, estimated blood loss (EBL), warm ischemia time (WIT), length of hospital stay, pre- and post-operative renal functions, complications and oncological outcomes were recorded, prospectively. RESULTS: Mean tumor size was 4.04 cm in OPN group and 3.56 cm in RAPN group (P = 0.27). Mean R.E.N.A.L nephrometry score was 6.35 in OPN group and 5.35 in RAPN group (P = 0.02). The mean operative time was 152 min in OPN group and 225 min in RAPN group (P = 0.006). The mean EBL in OPN and RAPN groups were 417 ml and 268 ml, respectively (P = 0.001). WIT in OPN group was significantly shorter than RAPN group (18.02 min vs. 23.33 min, P = 0.003). The mean drain removal time and the length of hospital stay were longer in OPN group. There were no significant differences in terms of renal functional outcomes and postoperative complications between groups. CONCLUSION: Minimally invasive surgical management of renal masses with RAPN offers better outcomes in terms of EBL and length of stay. However, the mean operative time and WIT were significantly shorter in OPN group. RAPN is a safe and effective minimally invasive alternative to OPN in terms of oncological and functional outcomes.

Comparison of long-term efficacy of desmopressin lyophilisate and enuretic alarm for monosymptomatic enuresis and assessment of predictive factors for success: a randomized prospective trial.

PURPOSE: We compared the long-term success of desmopressin sublingual lyophilisate formulation and enuretic alarm therapy in children with primary monosymptomatic nocturnal enuresis, and determined predictive factors for treatment success. MATERIALS AND METHODS: A total of 142 children with primary monosymptomatic nocturnal enuresis were randomized to receive treatment consisting of desmopressin or enuretic alarm for 6 months. Treatment compliance and response were reviewed monthly in each patient using a 30-day bed-wetting diary. Outcomes were assessed according to International Children's Continence Society criteria, and success rates at 6 and 12 months were compared for desmopressin and enuretic alarm. Additional intention to treat analyses were performed, considering cases with missing data as failures. Possible demographic factors predicting success were investigated by logistic regression analysis. RESULTS: Overall 4 children (5.2%) in the desmopressin group and 20 (30.7%) in the enuretic alarm group withdrew after randomization. Based on patients who completed 6 months of treatment, success (more than 90% reduction in wet nights per month) was achieved in 76.8% and 61.8% of children in the desmopressin and enuretic alarm groups, respectively. At 12 months 77.8% of those receiving desmopressin and 75% of those treated with enuretic alarm had success. However, long-term success rate was significantly higher with desmopressin (68.8% vs 46.2%) if intention to treat population was considered. Multivariate analysis revealed treatment group, severity of enuresis and monthly income as independent predictors of cure at 6 months. CONCLUSIONS: In compliant patients desmopressin lyophilisate and enuretic alarm provided equivalent success at the end of treatment and after extended followup. Alarm therapy had a high rate of early withdrawal from therapy and consequently lower rates of success on intention to treat analyses. Severe enuresis (more than 5 wet nights weekly) is an important predictive factor for cure after first-line treatment.

Comparison of surgical and functional outcomes of open, laparoscopic and robotic pyeloplasty for the treatment of ureteropelvic junction obstruction.

OBJECTIVE: To compare the surgical and functional outcomes of open, laparoscopic and robotic dismembered pyeloplasty for the treatment of patients with ureteropelvic junction obstruction (UPJO). MATERIAL AND METHODS: Between 2007 and 2012, a total of 56 patients underwent conventional open (Group 1; n=25), laparoscopic (Group 2; n=16), and robotic (Group 3; n=15) dismembered pyeloplasty operations. Preoperative evaluation was performed using urinalysis, urine culture, blood biochemistry, urinary ultra-sound, intravenous pyelogram (IVP) (optional) and Mercaptoacetyltriglycine (MAG-3) renal scan. The mean operation time, estimated blood loss, drain removal time, narcotic analgesic requirements, length of hospital stay and functional outcomes were compared among groups. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) v. 20 (IBM, Armonk, NY, USA) software, and statistically significant differences were determined using a p value <0.05. RESULTS: The mean age of the patients was 30 years in Group 1, 34.3 years in Group 2 and 32.9 years in Group 3. The mean operation time was 127, 130 and 114 min (p=0.32), and the estimated blood loss was 105, 31 and 28 mL, respectively (p=0.001). The drain was removed after 4.36 (±1.3), 2.33 (±0.6) and 1.8 (±0.6) days after surgery (p<0.001), and the mean hospital stay was 4.14 (±1.8), 2.8 (±0.75) and 2 (±1) days, respectively (p<0.001). Narcotic analgesic requirement was significantly higher in Group 1 compared with Groups 2 and 3 (p=0.02). The radiographic and symptomatic success rates were 96% in Group 1, 93.75% in Group 2 and 93.3% in Group 3. CONCLUSION: Laparoscopic and robotic pyeloplasty are feasible, effective, reliable and minimally invasive treatment approaches for the treatment of UPJO as compared with open dismembered pyeloplasty.

Ventral inlay labia minora graft urethroplasty for the management of female urethral strictures.

OBJECTIVE: To evaluate the functional outcomes of ventral inlay labia minora graft urethroplasty (VILGU) for the management of female urethral strictures. METHODS: Data of 7 consecutive women treated with VILGU between 2011 and 2013 were reviewed. Two patients had cystostomy tubes at repair, and 5 had undergone previous urethral dilations and urethrotomies. Clinical evaluation included assessment of the effect of voiding symptoms with American Urological Association (AUA) symptom score, uroflowmetry, voiding cystourethrography, and intraoperative urethrocystoscopy using a 6.5F pediatric ureterorenoscope. Preoperative AUA symptom score and peak urinary flow rate were compared with postoperative values. Cure was defined as the absence of any restenosis requiring additional intervention with subjective patient satisfaction at the last follow-up. RESULTS: Mean stricture length was 1.5 cm (range, 1-2.5), and mean operative time was 95 minutes (range, 70-110). With a mean follow-up of 18.2 months (range, 3-30), cure was achieved in 6 (86%) women. At the last follow-up, mean maximum urine flow (mL/s) increased from 3.9 ± 3.1 preoperatively to 22.7 ± 8.3 postoperatively (P <.001), and mean AUA symptom score decreased from 25.3 ± 5.2 preoperatively to 6.9 ± 3.7 postoperatively (P = .001). No fistulae developed after surgery. "De-novo" stress urinary incontinence was not evident in any case. CONCLUSION: VILGU effectively provides better urinary flow and significantly improves patient satisfaction in patients with female urethral stricture disease.

Predictive preoperative factors for positive surgical margins in robotic radical prostatectomy in low-risk prostate cancer.

OBJECTIVE: Positive surgical margins after radical prostatectomy for localized prostate cancer is a powerful predictor of PSA recurrence. Clinical stage, Gleason score and preoperative PSA are predictive factors for positive surgical margin after radical prostatectomy. In this study, we aimed to identify preoperative factors affecting surgical margin positivity in low-risk prostate cancer after robotic radical prostatectomy (RARP). MATERIAL AND METHODS: Between 2008 and 2011 (

The effect of prostate weight on the outcomes of robot-assisted radical prostatectomy.

OBJECTIVE: The effect of prostate volume on the surgical, functional, and oncological outcomes of robot assisted radical prostatectomy (RARP) was evaluated. MATERIAL AND METHODS: A total of 180 patients who underwent RARP and had at least a 1-year follow-up were included. The patients were divided into 3 groups based on prostate weight (Group 1: <45 g, Group 2: 45-75 g, and Group 3: >76 g). Erectile function and continence were evaluated at 3, 6, 9, and 12 months postoperatively. The International Index of Erectile Dysfunction (IIEF) score and daily pad usage were evaluated as indicators of erectile function and continence, respectively. The measurement of two prostate-specific antigen (PSA) values over 0.2 ng/mL was considered biochemical disease recurrence. RESULTS: Patients with larger prostates were older and had a longer operative time and higher PSA level compared with patients with smaller prostates (p<0.05). The positive surgical margin rate was higher in patients with smaller prostates (p=0.06). However, patients with a prostate weight <45 g had higher IIEF scores at 3 and 6 months. IIEF scores were similar at the end of the 1-year follow-up period. Pad usage and time to continence were higher in patients with larger prostates (p>0.05). CONCLUSION: Although prostate weight affected the surgical outcomes of RARP, the functional and oncological outcomes were similar among all patients. Long-term follow-up is needed to determine their impact on oncological outcomes.

Comparison of surgical and functional outcomes of minimally invasive and open pyeloplasty.

OBJECTIVE: To compare the surgical and functional outcomes of minimally invasive pyeloplasty versus open pyeloplasty. SUBJECTS AND METHODS: Between 2008 and 2010, 20 patients underwent transperitoneal minimally invasive (13 robot-assisted and 7 laparoscopic) pyeloplasty, and 22 patients underwent conventional open pyeloplasty. Operative and functional outcomes were compared between the minimally invasive and open pyeloplasty groups. The statistical analysis was performed using Fisher's exact test, unpaired t test, and Mann-Whitney U test. RESULTS: The mean age was 31 years in the minimally invasive group and 27 years in the open group. The mean operative time was 131 minutes in the minimally invasive group and 128 minutes in the open group (P=.71). The estimated blood loss was 30 mL in the minimally invasive group and 108 mL in the open group (P=.001). The drain was removed after 1.75 days and 4.48 days in the minimally invasive and open groups, respectively (P=.001). The mean hospital stay was 1.94 days and 4.19 days in the minimally invasive and open groups, respectively (P=.001). Crossing vessels were observed in 21% of all patients, and the transposition of the ureter was performed in all patients with an anterior crossing vessel. One patient in each group had symptomatic and radiographic recurrence and persistently obstructed drainage pattern on diuretic renography. The radiographic and symptomatic success rate was 95% in the minimally invasive group and 95.5% in the open group. CONCLUSIONS: Minimally invasive pyeloplasty has low morbidity, short length of stay, and less blood loss compared with open surgical repair. It is an effective and feasible minimally invasive treatment modality for ureteropelvic junction obstruction.

Minimum 1.5-year results of "surgeon-tailored" transvaginal mesh repair for female stress urinary incontinence and pelvic organ prolapse.

OBJECTIVE: To evaluate our minimum 1.5-year results with "surgeon-tailored" polypropylene mesh (STPM) in stress urinary incontinence treatment and the impact of concomitant pelvic organ prolapse repair on functional outcomes. METHODS: All patients who were treated for stress urinary incontinence and pelvic organ prolapse using STPM between 2006 and 2010 were reviewed. Fifty-two patients received transobturator midurethral sling alone. Concomitant pelvic organ prolapse repair was performed in 74 (67 cystocele, 14 rectocele). Pre- and postoperative evaluation included subjective assessment of the impact of voiding and prolapse symptoms with International Consultation on Incontinence-Short Form and Prolapse Quality of Life (P-QOL) questionnaires, uroflowmetry, and urodynamic studies when necessary. Surgical outcomes at the last follow-up and complications were compared between the transobturator midurethral sling and transobturator midurethral sling + pelvic organ prolapse repair groups. RESULTS: One-hundred eighteen women were available for analysis. With a mean follow-up of 33.4 and 41.2 months for transobturator midurethral sling and transobturator midurethral sling + pelvic organ prolapse repair groups, stress urinary incontinence was cured in 86.4% and 81.1% of the patients, respectively. Preoperative urge symptoms resolved in 53.8% and 62.5%, and de novo urge symptoms developed in 22% and 15% of patients with respect to study groups. Pelvic organ prolapse was cured in 98.6% patients, with a significant improvement in all domains of the P-QOL questionnaire at the last follow-up. Vaginal mesh erosions were detected in 11 (14.8%) patients with concomitant pelvic organ prolapse repair. CONCLUSION: STPM may represent a cost-effective option for stress urinary incontinence treatment. Concomitant pelvic organ prolapse repair with STPM does not affect incontinence outcomes and provides high anatomic success and patient satisfaction in the long term. However, mesh-related complications with this approach is a major concern that deserves further investigation of risk factors and better definition of patient selection criteria.

Factors that impact the outcome of minimally invasive pyeloplasty: results of the Multi-institutional Laparoscopic and Robotic Pyeloplasty Collaborative Group.

PURPOSE: We compared laparoscopic and robotic pyeloplasty to identify factors associated with procedural efficacy. MATERIALS AND METHODS: We conducted a retrospective multicenter trial incorporating 865 cases from 15 centers. We collected perioperative data including anatomical and procedural factors. Failure was defined subjectively as pain that was unchanged or worse per medical records after surgery. Radiographic failure was defined as unchanged or worsening drainage on renal scans or worsening hydronephrosis on computerized tomography. Bivariate analyses were performed on all outcomes and multivariate analysis was used to assess factors associated with decreased freedom from secondary procedures. RESULTS: Of the cases 759 (274 laparoscopic pyeloplasties with a mean followup of 15 months and 465 robotic pyeloplasties with a mean followup of 11 months, p <0.001) had sufficient data. Laparoscopic pyeloplasty, previous endopyelotomy and intraoperative crossing vessels were associated with decreased freedom from secondary procedures on bivariate analysis, with a 2-year freedom from secondary procedures of 87% for laparoscopic pyeloplasty vs 95% for robotic pyeloplasty, 81% vs 93% for patients with vs without previous endopyelotomy and 88% vs 95% for patients with vs without intraoperative crossing vessels, respectively. However, on multivariate analysis only previous endopyelotomy (HR 4.35) and intraoperative crossing vessels (HR 2.73) significantly impacted freedom from secondary procedures. CONCLUSIONS: Laparoscopic and robotic pyeloplasty are highly effective in treating ureteropelvic junction obstruction. There was no difference in their abilities to render the patient free from secondary procedures on multivariate analysis. Previous endopyelotomy and intraoperative crossing vessels reduced freedom from secondary procedures.

The learning curve of robot-assisted radical prostatectomy.

PURPOSE: To evaluate the learning curve of a surgeon with no previous laparoscopy experience in performing robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: A total of 120 patients with a 1-year follow-up after RARP were included to the study prospectively. Patients were grouped as the first, second, and third 40 patients. Surgical, oncologic, and functional outcomes were compared among groups. Analysis of variance, chi-square, and Kruskal-Wallis test were used for statistical analysis. RESULTS: All groups were similar with respect to age, prostate-specific antigen level, body mass index, Gleason score, and distribution of the clinical stage. The operative time was 182 minutes for group 1, 168 minutes for group 2, and 139 minutes for group 3 (P=0.01). Individual times of various stages of the procedure (dissection of the seminal vesicles, entering the extraperitoneal space and dissection of the endopelvic fascia, incision of the bladder neck, division of the prostatic pedicles and preservation of the neurovascular bundle, and urethrovesical anastomosis) decreased significantly over time. Estimated blood loss was 287 mL for group 1 238 mL for group 2, and 170 mL for group 3 (P=0.04). The length of stay was 5.1 days for group 1, 4.0 days for group 2, and 3.1 days for group 3 (P=0.005). Positive surgical margin rates were 22% (9) for group 1, 17% (7) for group 2, and 6% (2) for group 3 (P=0.03). While seven patients in group 1 and two patients in group 2 had biochemical recurrence, no patient in group 3 had biochemical recurrence (P=0.04). Continence rates at 12 months were 72.5%, 85%, and 92.5% in groups 1, 2, and 3, respectively (P=0.01). Potency rates at 12 months for groups 1, 2, and 3 were 60.5%, 66.7%, and 76.6%, respectively (P=0.03). CONCLUSION: Surgical, oncologic, and functional outcomes of RARP improve with increasing experience. Outcomes similar to the published series by high-volume centers could be achieved after 80 to 120 RARP cases.

Ureteroenteric anastomotic stricture: novel use of a cutting balloon dilator.

INTRODUCTION: Management of ureteroenteric strictures presents a significant challenge because of its intraabdominal location and morbidity associated with open surgical management. The peripheral cutting balloon microsurgical dilatation device (PCBD), approved by The United States Food and Drug Administration (USFDA) for use in coronary angioplasty, features a 2-cm noncompliant balloon with four microsurgical blades mounted longitudinally on its outer surface. We evaluated the feasibility and outcome of this cutting balloon dilator in the treatment of ureteroenteric anastomotic strictures. MATERIALS AND METHODS: Three patients with a 1-cm or less ureteroenteric stricture underwent a transluminal incision under fluoroscopic guidance. Percutaneous access was obtained and a guidewire was introduced into the renal pelvis and ureter in antegrade fashion and passed through the stricture. The exact length of the strictured segment was measured. The PCBD was deployed over the guidewire and the balloon was inflated at the stricture site. The maximum diameter of the inflated balloon was 8 mm. Approximately 30 seconds later, the balloon was deflated and the enlarged passage from the ureter to the ileal loop was verified under fluoroscopy. A ureteral stent was placed and removed at 6 weeks after the procedure. RESULTS: Postoperative computed tomography scans at 12 months revealed improved hydronephrosis. All patients were asymptomatic postoperatively. One patient had a solitary kidney and creatinine level decreased significantly following the procedure. CONCLUSION: Dilatation and incision with PCBD is a novel approach for the treatment of the short ureteroenteric anastomotic strictures. Long-term data need to be obtained to establish the efficacy of this technique.

Posterior reconstruction before anastomosis improves the anastomosis time during robot-assisted radical prostatectomy.

BACKGROUND AND OBJECTIVES: Our goal was to evaluate posterior reconstruction of the rhabdosphincter during robot-assisted radical prostatectomy and determine whether this technique decreased anastomotic time of a surgeon in training to perform vesicourethral reconstruction. METHODS: We reviewed the first 25 robot-assisted prostatectomies performed by 2 urology surgeons in training (surgeon 1 and surgeon 2). The patient populations were matched for age, Gleason score, clinical stage, and PSA. Whereas surgeon 1 performed the vesicourethral anastomosis without posterior reconstruction, surgeon 2 reapproximated Denonvilliers' fascia of the posterior bladder to the rhabdosphincter. Time for each surgeon to complete the anastomosis and clinical factors was compared. RESULTS: Surgeon 1 had a median anastomosis time of 25 minutes (range, 17 to 48), whereas surgeon 2 had a median anastomosis time of 15 minutes (range, 10 to 30) (P<0.001). Biopsy Gleason score, pathological tumor stage, perineural invasion, median age at the time of surgery, PSA, prostate weight, and estimated blood loss were not significantly different between surgeons (P>0.05). Pathological Gleason score (P=0.045) and total console time (surgeon 1-216 minutes, surgeon 2-176 minutes; P=0.002) were significantly different between surgeons. CONCLUSION: Posterior reconstruction prior to anastomosis decreases anastomosis time for robotic surgeons in training.