A Comprehensive Review of the Current State of Robot-assisted Laparoscopic Salvage Prostatectomy.

BACKGROUND AND OBJECTIVE: Salvage robot assisted radical prostatectomy (sRARP) is performed for patients with biochemical or biopsy proven, localized prostate cancer recurrences after radiation or ablative therapies. Traditionally, sRARP has been avoided by lower volume surgeons due to technical demand and high complication rates. Post-radiation sRARP outcomes studies exist but remain few in number. With increasing use of whole gland and focal ablative therapies, updates on sRARP in this setting are needed. The aim of this narrative review is to provide an overview of recently reviewed studies on the oncologic outcomes, functional outcomes, and complications after post-radiation and post-ablative sRARP. Tips and tricks are provided to guide surgeons who may perform sRARP. MATERIALS AND METHODS: We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010-2022 without limitation on study design. Only case reports, editorial comments, letters, and manuscripts in non-English languages were excluded. Key Content and Findings: Salvage robotic radical prostatectomy is performed in cases of biochemical recurrence after radiation or ablative therapies. Oncologic outcomes after sRARP are worse compared to primary surgery (pRARP) though improvements have been made with the robotic approach when compared to open salvage prostatectomy. Higher pre-sRARP PSA levels and more advanced pathologic stage portend worse oncologic outcomes. Patients meeting low-risk, EAU-biochemical recurrence criteria have improved oncologic outcomes compared to those with high-risk BCR. While complication rates in sRARP are higher compared to pRARP, Retzius sparing approaches may reduce complication rates, particularly rectal injuries. In comparison to the traditional open approach, sRARP is associated with a lower rate of bladder neck contracture. In terms of functional outcomes, potency rates after sRARP are poor and continence rates are low, though Retzius sparing approaches demonstrate acceptable recovery of urinary continence by 1 year, post-operatively. CONCLUSIONS: Advances in the robotic platform and improvement in robotic experience have resulted in acceptable complication rates after sRARP. However, oncologic and functional outcomes after sRARP in both the post-radiation and post-ablation settings are worse compared to pRARP. Thus, when engaging in shared decision making with patients regarding the initial management of localized prostate cancer, patients should be educated regarding oncologic and functional outcomes and complications in the case of biochemically recurrent prostate cancer that may require sRARP.

Safety and complications of continuation of aspirin therapy in patients undergoing robot-assisted laparoscopic simple prostatectomy.

To evaluate the safety and feasibility of continued perioperative aspirin at the time of robotic assisted simple prostatectomy (RASP). We performed a retrospective review of our IRB approved institutional database of patients who underwent RASP between 2013 and 2022. Comparative groups included patients taking aspirin in the perioperative period and those not taking aspirin pre-operatively. The primary outcome was any post-operative bleeding related complication using the modified Clavien-Dindo classification. Secondary outcomes included the identification of risk factors for increased blood loss in the entire study population, operative time, and blood transfusion requirement. 143 patients underwent RASP of which 55 (38.5%) patients continued perioperative aspirin therapy and 88 (61.5%) patients did not. Baseline demographics were similar between groups. Patients taking perioperative aspirin had a higher rate of hypertension (74.5% vs 58.0%, p = 0.04) and other cardiovascular disease (30.9% vs 11.4%, p = 0.007). Postoperative complications were similar between the groups (Clavien-Dindo ≥ 3; p = 0.43). Median blood loss (150 cc vs 150 cc, p = 0.38), percentage drop in hemoglobin (13.4 vs 13.2, p = 0.94) and blood transfusion rate (3.6 vs 1.1, p = 0.56) were also similar between groups. The median blood loss was 150 ml for the whole study population. On regression analysis, neither aspirin nor any other variable was associated with increased blood loss (> 150 ml). Aspirin can be safely continued perioperatively in patients undergoing RASP without any risk of bleeding related complications, blood loss, or increased transfusion rate.

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy.

Objective: We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre- and peri-operative variables associated with length of stay (LOS) greater than 3 days and readmission within 30 days. Methods: Records from 2008 to 2018 for "laparoscopy, surgical; partial nephrectomy" for prolonged LOS and readmission cohorts were compiled. Univariate analysis with Chi-square, t-tests, and multivariable logistic regression analysis with odds ratios (ORs), p-values, and 95% confidence intervals assessed statistical associations. Results: Totally, 20 306 records for LOS greater than 3 days and 15 854 for readmission within 30 days were available. Univariate and multivariable analysis exhibited similar results. For LOS greater than 3 days, undergoing non-elective surgery (OR=5.247), transfusion of greater than four units within 72 h prior to surgery (OR=5.072), pre-operative renal failure or dialysis (OR=2.941), and poor pre-operative functional status (OR=2.540) exhibited the strongest statistically significant associations. For hospital readmission within 30 days, loss in body weight greater than 10% in 6 months prior to surgery (OR=2.227) and bleeding disorders (OR=2.081) exhibited strongest statistically significant associations. Conclusion: Multiple pre- and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data. Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection, optimization strategies, and patient education.

Management of the distal ureter and bladder cuff at the time of nephroureterectomy: an overview of open, laparoscopic, and robotic approaches.

Radical nephroureterectomy remains the gold standard treatment for high-risk upper tract urothelial carcinoma. The procedure is subdivided into six main steps: nephrectomy, ureterectomy, bladder cuff excision, cystorrhaphy, template-based lymph node dissection, and perioperative instillation of chemotherapy. Crucial in performing radical nephroureterectomy is successful management of the distal ureter and bladder cuff. Improper, inadequate, or incomplete bladder cuff excision can lead to worse oncologic outcomes and inferior cancer-specific survival. Throughout the years, open, laparoscopic, endoscopic, and robotic approaches have all been reported in performing bladder cuff excision during radical nephroureterectomy. The procedure can be accomplished via an extravesical, intravesical or transvesical manner. Each approach has distinct advantages and disadvantages. The robotic approach offers inherent advantages including improved dexterity, range of motion, and visualization. Critical to choosing an approach, however, is surgeon experience and comfort level. To date, no data suggests superiority of one approach over another. Sound oncologic principles must be adhered to when performing radical nephroureterectomy and include (I) adequate bladder cuff excision, (II) lymphadenectomy, (III) no complications and (IV) negative surgical margins, and (V) perioperative instillation of chemotherapeutic agent. Herein, we describe the various approaches in performing a bladder cuff excision and provide technical commentary supporting the advantages and disadvantages of each technique.

Oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma: a literature review.

Background and Objective: Radical nephroureterectomy (RNU) represents the gold standard treatment for non-metastatic upper tract urothelial cancer. We sought to provide a comprehensive review of reported oncologic outcomes of the RNU procedure and of factors that might impact these outcomes. Methods: A non-systematic review of the literature was conducted by performing an electronic literature search using PubMed with "radical nephroureterectomy" and "oncologic outcomes" as free text search terms. Both original articles and systematic reviews were considered. Search was limited to articles in English that were published in the last 20 years. Key Content and Findings: Open and laparoscopic RNU offer comparable oncologic outcomes. In more recent years, the discussion has de facto shifted towards the "oncological safety" of robotic RNU, which also seems to offer comparable oncologic outcomes. Several studies have looked at the impact of different treatment-, patient- and tumor-related factors. Among treatment-related factors, attention has been given to diagnostic ureteroscopy and the risk of intravesical recurrence. Surgical wait time and perioperative blood transfusion have also been studied. Perioperative chemotherapy, specifically adjuvant therapy, was shown to improve survival. Among patient-related factors, baseline chronic kidney disease, diabetes mellitus, body mass index, and systemic inflammation have gained recent attention. Some tumor related factors, such as stage, grade, location, and multifocality may negatively impact survival outcomes. Lymphovascular invasion and histologic variants are clinically significant pathological findings. Conclusions: RNU is a procedure with measured long-term oncologic outcomes. Minimally invasive techniques have gained an established role as they seem to offer comparable oncologic "safety", although special attention is needed in relation to the method of bladder cuff excision. Robotic RNU is gaining popularity, and while evidence remains limited, the current literature supports the oncologic safety of this procedure. Several factors, which can be categorized as treatment-related, patient-related, and tumor-related, might impact the oncologic outcomes of UTUC patients undergoing RNU. These factors can provide crucial information to stratify patients based on their relative risk of disease recurrence and mortality which may guide clinical decision-making.

Robot-assisted partial nephrectomy for complex renal tumors: Analysis of a large multi-institutional database.

INTRODUCTION: Highly complex renal masses pose a challenge to urologic surgeons' ability to perform robotic partial nephrectomy (RPN). Given the increased utilization of the robotic approach for small renal masses, we sought to characterize the outcomes and determine the safety and feasibility of RPN for complex renal masses from our large multi-institutional cohort. METHODS: We performed a retrospective analysis of patients with R.E.N.A.L. Nephrometry Scores ≥10 who underwent RPN in our multi-institutional cohort (N = 372). Baseline demographic, clinical and tumor related characteristics were evaluated with the primary endpoint of trifecta achievement (defined as negative surgical margin, no major complications, and warm ischemia time ≤25 min). Relationships between variables were assessed using the chi-square test of independence, Fisher exact test, Mann-Whitney U test, and Kruskal Wallis test. Logistic regression was used to evaluate the relationship between baseline characteristics and trifecta achievement. RESULTS: Of 372 patients in the study, mean age was 58 years, and median BMI was 30.49 kg/m2. The median tumor size was 4.3 cm (3.0-5.9 cm). Most of the patients had R.E.N.A.L. scores of 10 (n = 253; 67.01%). Overall, trifecta was achieved in 72.04% of patients. Stratifying intraoperative and postoperative outcomes by R.E.N.A.L. scores, there was no significant difference in trifecta achievement, operative time, warm ischemia time (WIT), open conversion, major complication, or positive margin rates. Length of hospital stay was significantly longer for higher R.E.N.A.L. scores (median days 2 vs. 1, P = 0.012). Multivariate analyses for factors associated with trifecta achievement concluded that age and baseline eGFR were independently associated with trifecta achievement. CONCLUSION: RPN is a safe and reproducible procedure for complex tumors with R.E.N.A.L. Nephrometry scores ≥10. Our results suggest excellent rates of trifecta achievement and short-term functional outcomes when performed by experienced surgeons. Long-term oncological and functional evaluation are needed to further support this conclusion.

Transperitoneal Versus Retroperitoneal Robotic-Assisted Partial Nephrectomy in Patients with Obesity.

Introduction: We aim to compare transperitoneal (TP) and retroperitoneal (RP) robotic partial nephrectomy (RPN) in obese patients. Obesity and RP fat can complicate RPN, especially in the RP approach where working space is limited. Materials and Methods: Using a multi-institutional database, we analyzed 468 obese patients undergoing RPN for a renal mass (86 [18.38%] RP, 382 [81.62%] TP). Obesity was defined as body mass index ≥30 kg/m2*. A 1:1 propensity score matching was performed adjusting for age, previous abdominal surgery, tumor size, R.E.N.A.L nephrometry score, tumor location, surgical date, and participating centers. Baseline characteristics and perioperative and postoperative data were compared. Results: In the propensity score-matched cohort, 79 (50%) TP patients were matched with 79 (50%) RP patients. The RP group had more posterior tumors (67 [84.81%], RP versus 23 [29.11%], TP; P < .001), while the other baseline characteristics were comparable. Warm ischemia time (interquartile range; 15 [10, 12], RP versus 14 [10, 17] minutes, TP; P = .216), operative time (129 [116, 165], RP versus 130 [95, 180] minutes, TP; P = .687), estimated blood loss (50 [50, 100], RP versus 75 [50, 150] mL, TP; P = .129), length of stay (1 [1, 1], RP versus 1 [1, 2] day, TP; P = .319), and major complication rate (1 [1.27%], RP versus 3 [3.80%], TP; P = .620) were similar. No significant difference was observed in positive surgical margin rate and delta estimated glomerular filtration at follow-up. Conclusion: TP and RP RPN yielded similar perioperative and postoperative outcomes in obese patients. Obesity should not be a factor in determining optimal approach for RPN.

15-year biochemical failure, metastasis, salvage therapy, and cancer-specific and overall survival rates in men treated with robotic radical prostatectomy for PSA-screen detected prostate cancer.

BACKGROUND: An informed decision regarding a treatment option requires data on its long-term efficacy and side-effect profile. While the side-effects of robotic radical prostatectomy have been well-quantified, the data on its long-term efficacy are lacking. We here provide 15-year oncological outcomes of clinically-localized prostate cancer (CLPCa) patients treated with robot-assisted laparoscopic prostatectomy (RALP). METHODS: We treated 1,807 men with CLPCa with RALP between 2001 and 2005 and prospectively collected follow-up data through 2020. We examined the rates of biochemical failure (BCF), metastatic progression, secondary therapy use, PCa-specific mortality (PCSM), and overall survival (OS) using Kaplan-Meier and competing-risk cumulative incidence methods as appropriate. RESULTS: The median follow-up was 14.1 years. Six hundred eight and 312 men had D'Amico intermediate- and high-risk disease, respectively. Overall, the 15-year rates of BCF, metastasis, secondary therapy use, PCSM, and OS were 28.1%, 4.0%, 16.3%, 2.5%, and 82.1%, respectively. The rates of oncologic failure increased with increasing D'Amico (preoperative) and Diaz (postoperative) risk scores - BCF, metastasis, and PCSM rates in D'Amico low-, intermediate-, and high-risk groups at 15-years were 15.2%, 38.3%, and 44.1% [BCF], 1.1%, 4.1%, and 13.0% [metastasis], and 0.5%, 3.4%, and 6.6% [PCSM], respectively, and in Diaz risk groups 1, 2, 3, 4, and 5 were 5.5%, 20.6%, 41.8%, 66.9%, and 89.2% [BCF], 0%, 0.5%, 3.2%, 20.5%, and 60.0% [metastasis], and 0%, 0.8%, 0.6%, 13.5%, and 37.5% [PCSM], respectively. The OS rates in D'Amico low-to-high and Diaz 1-to-5 risk groups at 15-years were 85.9%, 78.6%, and 75.2%, and 89.4%, 83.2%, 80.6%, 67.2%, and 23.4%, respectively. CONCLUSIONS: Men diagnosed with clinically-localized prostate cancer in the contemporaneous PSA-screening era and treated with RALP achieve durable long-term oncological control. The data reported here (in a risk-stratified manner) represent the longest follow-up after robotic radical prostatectomy, and as such, should be of value when counseling patients regarding expected oncologic outcomes from RALP.

Operative and oncological outcomes of salvage robotic radical and partial nephrectomy: a multicenter experience.

We aim to describe the perioperative and oncological outcomes for salvage robotic partial nephrectomy (sRPN) and salvage robotic radical nephrectomy (sRRN). Using a prospectively maintained multi-institutional database, we compared baseline clinical characteristics and perioperative and postoperative outcomes, including pathological stage, tumor histology, operative time, ischemia time, estimated blood loss (EBL), length of stay (LOS), postoperative complication rate, recurrence rate, and mortality. We identified a total of 58 patients who had undergone robotic salvage surgery for a recurrent renal mass, of which 22 (38%) had sRRN and 36 (62%) had sRPN. Ischemia time for sRPN was 14 min. The median EBL was 100 mL in both groups (p = 0.581). One intraoperative complication occurred during sRRN, while three occurred during sRPN cases (p = 1.000). The median LOS was 2 days for sRRN and 1 day for sRPN (p = 0.039). Postoperatively, one major complication occurred after sRRN and two after sRPN (p = 1.000). The recurrence reported after sRRN was 5% and 3% after sRPN. Among the patients who underwent sRRN, the two most prevalent stages were pT1a (27%) and pT3a (27%). Similarly, the two most prevalent stages in sRPN patients were pT1a (69%) and pT3a (6%). sRRN and sRPN have similar operative and perioperative outcomes. sRPN is a safe and feasible procedure when performed by experienced surgeons. Future studies on large cohorts are essential to better characterize the importance and benefit of salvage partial nephrectomies.

Robot-Assisted Simple Prostatectomy: A Comparison of Primary Simple Prostatectomy vs Salvage Simple Prostatectomy in Treatment of Lower Urinary Tract Symptoms.

Purpose: Simple prostatectomy is indicated in patients with enlarged glands (>80 g) who present with lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia. Salvage robotic simple prostatectomy (SSP) is defined as simple prostatectomy after failed transurethral procedure. The aim of this study is to evaluate the efficacy of primary robotic simple prostatectomy (PSP) vs SSP in ameliorating LUTS. Materials and Methods: We retrospectively reviewed 124 patients who underwent RSP between 2013 and 2021. Indications for surgery were enlarged prostate, bothersome LUTS, or symptoms refractory to medical management and/or previous prostate surgery. PSP and SSP preoperative, perioperative, and postoperative variables were recorded. The severity of LUTS was assessed using the International Prostate Symptoms Score (IPSS). Two-tailed t-tests were performed to compare primary vs salvage RSP cohorts at a p-value of 0.05. Results: Of 124 patients who underwent RSP, 98 were primary and 26 were in the salvage setting with 19 patients undergoing prior transurethral resection of the prostate, 3 status post-transurethral microwave therapy, 1 status post-transurethral needle ablation of the prostate, and 3 status post-UroLIFT. Mean length of stay following RSP was 1.87 (days). At mean follow-up of ∼12 months, no patient required reoperation for LUTS. Preoperative IPSS for primary and salvage RSP was 18.56 and 16.25, respectively (p = 0.36), and postoperative IPSS for primary and salvage RSP was 5.33 and 8.00, respectively (p = 0.38). Conclusion: Regardless of primary or salvage indication, RSP remains a highly efficient and durable procedure for improvement in LUTS. RSP performed in the salvage setting greatly improved urinary function outcomes in patients after failure of previous transurethral procedures.

The State of Robotic Partial Nephrectomy: Operative, Functional, and Oncological Outcomes From A Robust Multi-Institution Collaborative.

OBJECTIVE: To describe the most recent surgical, functional, and oncological outcomes of RPN utilizing one of the largest, prospectively maintained, multi-institution consortium of patients undergoing robotic renal surgery. MATERIALS AND METHODS: Data was obtained from a prospectively maintained multi-institutional database of patients who underwent RPN for clinically localized kidney cancer between 2018 and 2022 by 9 high-volume surgeons. Demographic and tumor characteristics as well as operative, functional, and oncological outcomes were queried. RESULTS: A total of 2836 patients underwent RPN. Intraoperative, postoperative, and 30-day major complication rates were 2.68%, 11.39%, and 3.24%, respectively. Median tumor size was 3.0 cm. Tumors with low complexity had a shorter median operative time, lower median EBL, shorter median ischemia time, lower postoperative complication rate, and lower decline in renal function There was no significant difference between tumor complexities with respect to the rate of conversion to radical nephrectomy, conversion to open, major complications, and positive margins. Lower BMI, smaller clinical tumor size, lower tumor complexity, and higher baseline eGFR were significantly associated with trifecta achievement. CONCLUSION: Patient BMI, baseline eGFR, and tumor characteristics such as size and complexity are the most important predictors of trifecta achievement. Patients with complex tumors should be counseled that they are at increased risk of complications and worsening renal function after robotic partial nephrectomy.

A comparison of outcomes between transperitoneal and retroperitoneal robotic assisted partial nephrectomy in patients with completely endophytic kidney tumors.

INTRODUCTION: Retroperitoneal robotic partial nephrectomy (RPN) has been shown to have comparable outcomes to the transperitoneal approach for renal tumors. However, this may not be true for completely endophytic tumors as they pose significant challenges in RPN with increased complication rates. Hence, we sought to compare the safety and feasibility of retroperitoneal RPN to transperitoneal RPN for completely endophytic tumors. METHODS: We performed a retrospective analysis of patients who underwent RPN for a completely endophytic renal mass using either transperitoneal or retroperitoneal approach from our multi-institutional database (n = 177). Patients who had a solitary kidney, prior ipsilateral surgery, multiple/bilateral tumors, and horseshoe kidneys were excluded from the analysis. Overall, 156 patients were evaluated (112 [71.8%] transperitoneal, 44 [28.2%] retroperitoneal). Baseline characteristics, perioperative and postoperative data were compared between the surgical transperitoneal and retroperitoneal approach using Chi-square test, Fishers exact test, t test, Mood median test and Mann Whitney U test. RESULTS: Of the 156 patients in this study, 86 (56.9%) were male and the mean (SD) age was 58 (13) years. Baseline characteristics were comparable between the 2 approaches. Compared to transperitoneal approach, retroperitoneal approach had similar ischemia time (19.6 [SD = 7.6] minutes vs. 19.5 [SD = 10.2] minutes, P = 0.952), operative time (157.5 [SD = 44.8] minutes vs. 160.2 [SD = 47.3] minutes, P = 0.746), median estimated blood loss (50 ml [IQR: 50, 150] vs. 100 ml [IQR: 50, 200], P = 0.313), median length of stay (1 [IQR: 1, 2] day vs. 1 [IQR: 1, 2] day, P = 0.126) and major complication rate (2 [4.6%] vs. 3 [2.7%], P = 0.621). No difference was observed in positive surgical margin rate (P = 0.1.00), delta eGFR (P = 0.797) and de novo chronic kidney disease occurrence (P = 1.000). CONCLUSION: Retroperitoneal and transperitoneal RPN yielded similar perioperative and functional outcomes in patients with completely endophytic tumors. In well-selected patients with purely endophytic tumors, either a retroperitoneal or transperitoneal approach could be considered without compromising perioperative and postoperative outcomes.

Robot-Assisted Laparoscopic Ureteral Reconstruction for Malignant Pathology: Single-Center Experience with Analysis of Perioperative, Functional, and Oncologic Outcomes.

Introduction: Radical nephroureterectomy with bladder cuff excision (BCE) is the standard of care all high-risk upper tract urothelial carcinomas. With continued advancements, robot-assisted segmental ureteral resection can be employed for ureteral tumors for ipsilateral renal preservation. Herein, we are presenting our experience of different techniques classified by the affected ureteral segment, along with perioperative and intermediate to long-term functional and oncologic outcomes. Methods: From January 2008 to June 2021, a total of 17 patients underwent robot-assisted renal preserving excisional procedures for ureteral tumors. We collected and analyzed baseline, perioperative and follow-up outcomes parameters from our prospectively maintained institutional database. Eleven patients underwent segmental ureterectomy (SU) with BCE and ureteroneocystostomy with psoas hitch, five patients underwent SU with ureteroureteral anastomosis with/without psoas hitch, and one patient underwent ileal patch interposition after segmental ureteral excision. Results: Although majority of the patients had inconclusive or low-grade pathology on initial ureteroscopic biopsies, 73.33% of the patients were found to have high-grade tumors on final pathology report. Median tumor size was 2.7 cm (1-5.5 cm), and the median operative duration was 193 minutes (142-400 minutes). None of the procedures required conversion to open. Overall, only one patient (5.9%) had Clavien-Dindo grade ≥ III complication (pelvic abscess). At median follow-up of 41 months (7-156 months), four patients (26.67%) developed urothelial recurrences out of which only one patient required nephroureterectomy. Overall survival and nephroureterectomy-free survival were 86.67% and 92.31%, respectively. Conclusions: Our study provides a comprehensive review of various surgical approaches of robot-assisted renal sparing management for ureteral tumors. These procedures are surgically safe, feasible, and effective with satisfactory oncologic outcomes at intermediate to long-term follow-up. These procedures may be safely employed in select patients with a localized ureteral tumor to salvage the ipsilateral kidney and estimated glomerular filtration rate.

Urothelial Carcinoma Recurrence With an Ileal Conduit: Multimodal Management With Extirpative Surgery, Chemotherapy, and Immunotherapy.

Ileal conduit (IC) is the most performed urinary diversion after radical cystectomy (RC) for urothelial carcinoma (UC) of the bladder. While UC recurrence after RC is well-described, recurrence of UC within a urinary diversion is much less prevalent, and thus, management of these lesions is not well understood. Here, we report the case of a 59-year-old male with a history of invasive UC with glandular differentiation of the urinary bladder who had carcinoma in situ recurrence after induction, intravesical Bacille Calmette-Guerin therapy. He underwent robot-assisted laparoscopic radical cystoprostatectomy (RALC) with bilateral pelvic lymph node dissection and intracorporal ileal conduit (IC) urinary diversion. Two years later, he presented to the emergency department with hematuria. Computed tomography demonstrated a mass within the IC. He subsequently underwent IC resection and ligation of bilateral ureters and had permanent nephrostomy tubes placed, with the final pathology confirming high-grade UC. Positron emission tomography revealed hypermetabolic soft tissue implants within the greater omentum and retroperitoneum for which he underwent fine-needle aspiration, demonstrating recurrence of poorly differentiated UC. Ultimately, the patient started treatment with systemic gemcitabine and carboplatin and completed 4 cycles before transitioning to maintenance avelumab therapy. No disease progression was noted at 16 months post-treatment. Herein, we present a review of the literature and our management of the present patient.

A Propensity-Matched Comparison of the Perioperative Outcomes Between Single-Port and Multi-Port Robotic Assisted Partial Nephrectomy: A Report from the Single Port Advanced Research Consortium (SPARC).

Purpose: Single-port (SP) robotic surgery is a new technology and early in its adoption curve. The goal of this study is to compare the perioperative outcomes of SP to multi-port (MP) robotic technology for partial nephrectomy. Materials and Methods: This is a prospective cohort study of patients who have undergone robot-assisted partial nephrectomy using SP and MP technology. Baseline demographic, clinical, and tumor-specific characteristics and perioperative outcomes were compared using χ2, t-test, and Mann-Whitney U test in the overall cohort and in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. Results: After propensity matching, 146 SP patients were matched with 146 MP patients. SP and MP groups had similar mean age (58 ± 12 years vs 59 ± 12 years; p = 0.606) and proportion of men (54.11% vs 52.05%; p = 0.725). The SP had a longer mean ischemia (18.29 ± 10.49 minutes vs 13.79 ± 6.29 minutes; p < 0.001). Estimated blood loss (EBL) and length of hospital stay (LOS), operative time, positive margin rate, and any complication rate were similar between the two groups. Conclusions: SP partial nephrectomy had a longer ischemia time, and a comparable LOS, EBL, operative time, positive margin rates, and complication rates to MP. These early data are encouraging. However, the role of SP requires further study and should evaluate safety and long-term data when compared with the standard MP technique.

The role of RENAL score in predicting complications after robotic partial nephrectomy.

BACKGROUND: The aim of this study was to evaluate the association between tumor complexity based on RENAL nephrometry score and complications. METHODS: We retrospectively identified 2555 patients who underwent RPN for renal cell carcinoma. Major complication was defined as Clavien Grade ≥3. The relationship between baseline demographic, clinical characteristics, perioperative and postoperative outcomes, and tumor complexity were assessed using χ2 test of independence, Fisher's Exact Test and Kruskal Wallis Test. An unadjusted and adjusted logistic regression model was used to assess the relationship between major complication and demographic, clinical characteristics, and perioperative outcomes. RESULTS: There was a significant relationship between tumor complexity and WIT (P<0.001), operative time (P<0.001), estimated blood loss (P<0.001), and major complication (P=0.019). However, there was no relationship with overall complications (P=0.237) and length of stay (LOS) (P=0.085). In the unadjusted model, higher tumor complexity was associated with major complication (P=0.009). Controlling for other variables, there was no significant difference between major complication and tumor complexity (low vs. moderate, P=0.142 and high, P=0.204). LOS (P<0.001) and operative time (P=0.025) remained a significant predictor of major complication in the adjusted model. CONCLUSIONS: Tumor complexity is not associated with an increase in overall or major complication rate after RPN. Experience in high-volume centers is demonstrating a standardization of low complications rates after RPN independent of tumor complexity.

Early return to continence and potency with use of dehydrated human umbilical cord graft at the time of robot-assisted radical prostatectomy: A case study and analysis of relevant literature.

INTRODUCTION: Robot-assisted radical prostatectomy often causes damage to the neurovascular bundle which results in erectile dysfunction and urinary incontinence. Recovery may take months; however, dehydrated umbilical cord allografts appear to offer an advantage in terms of a faster return to continence and potency. CASE PRESENTATION: A 67-year-old male, who presented with intermediate-risk prostate cancer, underwent a bilateral nerve-sparing radical prostatectomy and placement of dehydrated human umbilical cord graft. Four weeks post-prostatectomy, the patient reported minimal stress urinary incontinence and erections with 75% rigidity. Three months post-prostatectomy, the patient noted improved continence and erections with 100% rigidity. CONCLUSION: To our knowledge, this is the second experience reported in the literature evaluating the use of umbilical cord allograft during robot-assisted radical prostatectomy, with promising results, and it is the first reported case to analyze potency as an outcome.