Impact of hospital volume and surgeon volume on robot-assisted partial nephrectomy outcomes: a multicentre study.

OBJECTIVE: To assess the impact of hospital volume (HV) and surgeon volume (SV) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: All consecutive patients who underwent a RAPN from 2009 to 2015, at 11 institutions, were included in a retrospective study. To evaluate the impact of HV, we divided RAPN into four quartiles according to the caseload per year: low HV (<20/year), moderate HV (20-44/year), high HV (45-70/year), and very high HV (>70/year). The SV was also divided into four quartiles: low SV (<7/year), moderate SV (7-14/year), high SV (15-30/year), and very high SV (>30/year). The primary endpoint was the Trifecta defined as the following combination: no complications, warm ischaemia time (WIT) <25 min, and negative surgical margins. RESULTS: In total, 1 222 RAPN were included. The mean (sd) caseload per hospital per year was 44.9 (26.7) RAPNs and the mean (sd) caseload per surgeon per year was 19.2 (14.9) RAPNs. The Trifecta achievement rate increased significantly with SV (69.9% vs 72.8% vs 73% vs 86.1%; P < 0.001) and HV (60.3% vs 72.3% vs 86.2% vs 82.4%; P < 0.001). The positive surgical margins (PSM) rate (P = 0.02), length of hospital stay (LOS; P < 0.001), WIT (P < 0.001), and operative time (P < 0.001), all decreased significantly with increasing SV. The PSM rate (P = 0.02), LOS (P < 0.001), WIT (P < 0.001), operative time (P < 0.001), and major complications rate (P = 0.01), all decreased significantly with increasing HV. In multivariate analysis adjusting for HV and SV (model 3), HV remained the main predictive factor of Trifecta achievement (odds ratio [OR] 3.70 for very high vs low HV; P < 0.001), whereas SV was not associated with Trifecta achievement (OR 1.58 for very high vs low SV; P = 0.34). CONCLUSION: In this multicentre study HV and SV both greatly influenced RAPN perioperative outcomes, but HV appeared to have a greater impact than SV.

Sildenafil non-responders: haemodynamic and morphometric studies.

OBJECTIVES: Most of the available data on efficacy for sildenafil are based on a questionnaire and erectile dysfunction (ED) is classified with minor or severe organic factors. To better select sildenafil responders and non-responders, we have conducted a haemodynamic and morphometric study in sildenafil non-responders. METHODS: Thirty patients with ED aged from 28 to 74 years-old did not respond to 8 attempts of 100 mg of sildenafil. They underwent hormonal measurements, intracavernous injection (ICI 20 microg PgE1) followed by Doppler examination and cavernosometry. A penile biopsy was performed under local anesthesia. A quantification of the cavernous smooth muscle (SMC) was performed with a computerized image analysis after staining with actin anti-actin. RESULTS: Twenty-eight patients had a very poor ICI response. Five patients were diabetic and 2 had low testosterone level. Eight patients had arterial lesions, 15 had venous leak and 5 both lesions. They all had reduction of SMC (<35%). No biological and vascular abnormality was observed in two patients. They had a percentage of SMC of 38% and 42%. No complication was observed with the penile biopsy. CONCLUSIONS: Severe vascular lesions and atrophy of SMC are mainly observed in sildenafil non-responders. The age, diabetes and low testosterone level seem not to be related with the failures.