An Indirect Comparison of Newer Minimally Invasive Treatments for Benign Prostatic Hyperplasia: A Network Meta-Analysis Model.

Objective: This study was designed to provide an indirect comparison of the urinary and sexual domain outcomes and complications after newer minimally invasive surgical therapy (MIST) of Aquablation, Rezum, and UroLift for benign prostatic hyperplasia (BPH) for transurethral resection of prostate (TURP). Methods: We searched Embase, Medline, and Cochrane in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, in December 2019. Only randomized clinical trials (RCTs) that reported outcomes after treatment of BPH for prostate less than 80 g with Aquablation, Rezum, or UroLift were included in the analysis. Results: A total of four RCTs reporting the outcomes after treatment with newer MIST for BPH were identified. Patients undergoing the resective procedures, that is, TURP and Aquablation, had greater improvement in urinary domain outcomes: International Prostate Symptom Score, quality of life, peak flow rate, and postvoiding residual compared to patients undergoing nonresective procedures: UroLift and Rezum. Patients in UroLift group maintained a higher sexual function domain score compared to TURP, but not Aquablation. Our multiple comparison analysis did not reveal a significant difference in urinary and sexual domain scores between patients undergoing UroLift and Rezum at 24 months of follow-up. Conclusions: Aquablation and TURP necessitate general or regional anesthesia and both produced significantly better urinary domain scores compared to Rezum and UroLift. On the other hand, UroLift demonstrated better sexual function domain scores compared to TURP, but not Aquablation. There was no significant difference in urinary domain scores between UroLift and Rezum at 24 months of follow-up.

Safety of Live Robotic Surgery: Results from a Single Institution.

BACKGROUND: Live surgery events (LSEs) have become one of the most attended activities at surgical meetings and provide a unique opportunity for the audience to observe the decision-making process used by skilled and experienced surgeons in real time. However, there is an ongoing discussion on whether patients treated during LSE are at higher risk of complications. OBJECTIVE: To examine LSE outcomes for robot-assisted radical prostatectomy (RARP) and establish patient safety and efficacy. DESIGN, SETTING, AND PARTICIPANTS: From January 2008 to April 2016, >9000 patients underwent RARP at our institution, performed by a single surgeon. From this group, 36 patients underwent live RARP surgery (LS group) transmitted via video link from our institution to an external congress. A control group was obtained from our database to compare outcomes between the LS group and patients undergoing RARP under regular circumstances. The data were prospectively collected in a customized database and retrospectively analyzed. INTERVENTION: All patients underwent RARP performed by a single surgeon at our institution. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Postoperative outcomes were compared between the LS (n=36) and the control (n=108) groups using Student's t test and analysis of variance for continuous variables, and a two-tailed Fisher's exact test for categorical variables. Statistical significance was set at p<0.05. RESULTS AND LIMITATIONS: There were no significant differences in baseline characteristics (age, body mass index, comorbidities, preoperative Gleason score, Sexual Health Inventory for Men score and American Urological Association symptom score) between the groups. The median console time was shorter for the LS group (73min, interquartile range [IQR] 70-79) than for the control group (78min, IQR 75-87; p=0.0371). No major complications were reported in either group, and only four minor complications were observed in the control group (p=0.2415). After median follow-up of 31 mo (IQR 18-50), only one patient (2.77%) in the LS group experienced biochemical recurrence, compared to four (3.71%) in the control group (p=0.7927). There was no significant difference in continence rates between the LS and control groups (97.22% vs 93.52%; p=0.7768). No differences in potency rate were evident by the end of the follow-up period (LS 69.44%, control group 70.37%; p=0.8432). The retrospective nature, the lack of randomization, and the single-institution experience are limitations of the study. CONCLUSIONS: In this series of live transmitted RARPs, perioperative results (oncological and functional outcomes and complications) were similar to those found in daily practice. After careful patient selection, LSEs are safe with minimal patient morbidity in the hands of an experienced surgeon working with a familiar surgical team. Further evaluation of the results from other surgeons at other centers is necessary. PATIENT SUMMARY: We investigated the safety of surgeries broadcast live from our institution. We found that outcomes were similar to those for patients undergoing surgery under regular circumstances in terms of the rate of complications and oncological and functional outcomes. We conclude that live transmitted surgery is safe in well-selected patients in the hands of an experienced surgeon.

Use of Scaffolding Tissue Biografts To Bolster Vesicourethral Anastomosis During Salvage Robot-assisted Prostatectomy Reduces Leak Rates and Catheter Times.

BACKGROUND: One of the key factors contributing to morbidity associated with salvage radical prostatectomy is a significant vesicourethral anastomosis (VUA) disruption or postoperative tissue dehiscence in the region of the distal bladder neck that causes a large prolonged urinary leak, perineal pain, and delayed catheter removal. OBJECTIVE: To describe our surgical technique using a urinary bladder extracellular matrix (UB-ECM) scaffold incorporated into the base of the VUA and the distal bladder neck during salvage robot-assisted radical prostatectomy (sRARP) and to assess outcomes and safety. DESIGN, SETTING, AND PARTICIPANTS: From March to July 2015, 15 patients underwent sRARP performed after primary therapy failure by a single surgeon. Two other groups were identified via analysis of propensity score matching. Group 2 (n=45) underwent sRARP with standard suturing without use of the graft. Group 3 (control group; n=45) underwent primary RARP with no graft placement. These two groups were compared group 1 (n=15), in which patients underwent sRARP and received the scaffold in a 1:3:3 match. SURGICAL PROCEDURE: sRARP with use of a UB-ECM scaffold in the posterior aspect of the VUA and distal bladder neck. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Clinical data were prospectively collected in a customized database and retrospectively analyzed. Analysis of variance and Student's t-test were used to test the equality of means for continuous variables, while the χ2 test was used to test categorical variables. RESULTS AND LIMITATIONS: There were no anastomotic leaks in the control group, with an average catheter time of 6.3 d (5-7 d). However, a clinically significant VUA/bladder neck disruption was observed in 16 patients (35.5%) in group 2, with a median catheterization time of 17.4 d (9-47 d), while in group 1 only one patient (6.66%) had a significant anastomotic leak on cystography (p=0.045), with median catheterization time of 11.2 d (10-52 d) for this group (p<0.05). CONCLUSIONS: Incorporation of a UB-ECM scaffold into the base of the VUA and distal bladder neck should be considered as an option to decrease morbidity associated with sRARP since it decreased the rate of VUA disruption, enhanced healing, and reduced catheterization time. This technique could be a valuable tool for all surgeons performing sRARP. PATIENT SUMMARY: We investigated the use of a scaffolding tissue graft when connecting the urethra to the bladder during salvage robot-assisted laparoscopic prostatectomy. This technique was found to be effective and safe.