Open versus robotic partial nephrectomy in obese patients: a multi-institutional propensity score-matched analysis (UroCCR 43-Robese study).

INTRODUCTION: There is limited evidence on the outcomes of robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN) in obese patients (BMI ≥ 30 kg/m2). In this study, we aimed to compare perioperative and oncological outcomes of RPN and OPN. METHODS: We relied on data from patients who underwent PN from 2009 to 2017 at 16 departments of urology participating in the UroCCR network, which were collected prospectively. In an effort to adjust for potential confounders, a propensity-score matching was performed. Perioperative outcomes were compared between OPN and RPN patients. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: Overall, 1277 obese patients (932 robotic and 345 open were included. After propensity score matching, 166 OPN and 166 RPN individuals were considered for the study purposes; no statistically significant difference among baseline demographic or tumor-specific characteristics was present. A higher overall complication rate and major complications rate were recorded in the OPN group (37 vs. 25%, p = 0.01 and 21 vs. 10%, p = 0.007; respectively). The length of stay was also significantly longer in the OPN group, before and after propensity-score matching (p < 0.001). There were no significant differences in Warm ischemia time (p = 0.66), absolute change in eGFR (p = 0.45) and positive surgical margins (p = 0.12). At a median postoperative follow-up period of 24 (8-40) months, DFS and OS were similar in the two groups (all p > 0.05). CONCLUSIONS: In this study, RPN was associated with better perioperative outcomes (improvement of major complications rate and LOS) than OPN. The oncological outcomes were found to be similar between the two approaches.

Who Is at Risk of Death after Renal Trauma? An Analysis of Thirty-Day Mortality after 1,799 Cases of Renal Trauma.

INTRODUCTION: The aim of the study was to report the 30-day mortality (30DM) after renal trauma and identify the risk factors associated with death. METHODS: The TRAUMAFUF project was a retrospective multi-institutional study including all patients with renal trauma admitted to 17 French hospitals between 2005 and 2015. The included population focused on patients of all age groups who underwent renal trauma during the study period. The primary outcome was death within 30 days following trauma. The multivariate logistic regression model with a stepwise backward elimination was used to identify predictive factors of 30DM. RESULTS: Data on 1,799 renal trauma were recorded over the 10-year period. There were 59 deaths within 30 days of renal trauma, conferring a 30DM rate of 3.27%. Renal trauma was directly involved in 5 deaths (8.5% of all deaths, 0.3% of all renal trauma). Multivariate stepwise logistic regression analysis revealed that age >40 years (odds ratio [OR] 2.18; 95% confidence interval [CI]: 1.20-3.99; p = 0.01), hemodynamic instability (OR 4.67; 95% CI: 2.49-9; p < 0.001), anemia (OR 3.89; 95% CI: 1.94-8.37; p < 0.001), bilateral renal trauma (OR 6.77; 95% CI: 2.83-15.61; p < 0.001), arterial contrast extravasation (OR 2.09; 95% CI: 1.09-3.96; p = 0.02), and concomitant visceral and bone injuries (OR 6.57; 95% CI: 2.41-23.14; p < 0.001) were independent predictors of 30DM. CONCLUSION: Our large multi-institutional study supports that the 30DM of 3.27% after renal trauma is due to the high degree of associated injuries and was rarely a consequence of renal trauma alone. Age >40 years, hemodynamic instability, anemia, bilateral renal trauma, arterial contrast extravasation, and concomitant visceral and bone lesions were predictors of death. These results can help clinicians to identify high-risk patients.

Factors Predictive of Selective Angioembolization Failure for Moderate- to High-grade Renal Trauma: A French Multi-institutional Study.

BACKGROUND: Angiography with selective angioembolization (SAE) is safe and effective in addressing bleeding in patients with renal trauma. However, there are no validated criteria to predict SAE efficacy. OBJECTIVE: To evaluate factors predictive of SAE failure after moderate- to high-grade renal trauma. DESIGN, SETTING, AND PARTICIPANTS: TRAUMAFUF was a retrospective multi-institutional study including all patients who underwent upfront SAE for renal trauma in 17 French hospitals between 2005 and 2015. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was SAE efficacy, defined as the absence of repeat SAE, salvage nephrectomy, and/or death for each patient. RESULTS AND LIMITATIONS: Out of 1770 consecutive patients with renal trauma, 170 (9.6%) with moderate- to high-grade renal trauma underwent SAE. Overall upfront SAE was successful in 131 patients (77%) and failed in 39 patients: six patients died after the embolization, ten underwent repeat SAE, 22 underwent open nephrectomy, and one underwent open surgical exploration. In multivariate logistic regression analysis, gross hematuria (odds ratio [OR] 3.16, 95% confidence interval [CI] 1.29-8.49; p=0.015), hemodynamic instability (OR 3.29, 95% CI 1.37-8.22; p=0.009), grade V trauma (OR 2.86, 95% CI 1.06-7.72; p=0.036), and urinary extravasation (OR 3.49, 95% CI 1.42-8.83; p=0.007) were predictors of SAE failure. The success rate was 64.7% (22/34) for patients with grade V trauma and 59.6% (31/52) for those with hemodynamic instability. The study was limited by its retrospective design and the lack of a control group managed with either surgery or surveillance. CONCLUSIONS: We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure. However, success rates in these subgroups remained relatively high, suggesting that SAE might be appropriate for those patients as well. PATIENT SUMMARY: Selective angioembolization (SAE) is a useful alternative to nephrectomy to address bleeding in patients with renal trauma. Currently, there are no validated criteria to predict SAE efficacy. We found that gross hematuria, hemodynamic instability, grade V trauma, and urinary extravasation were significant predictors of SAE failure.

Predictive factors of urinary incontinence after holmium laser enucleation of the prostate: a multicentric evaluation.

OBJECTIVE: To evaluate predictive factors of urinary incontinence (UI) after holmium laser enucleation of the prostate (HoLEP). METHODS: Patients (n = 2346) were included in a retrospective multicentric study from April 2012 to November 2017. Patients' characteristics (age, BMI, percentage with diabetes), preoperative data (IPSS score, whole gland volume, urinary drainage), operative data (enucleation time, enucleation efficiency, tissue enucleated weight, total delivered energy) and postoperative data were recorded. Absence of UI was defined as no pads at 3 and 6 months. Surgeon experience was stratified in three categories: beginners (< 21 cases), intermediate (21-40 cases) and experienced (> 40 cases). Multivariate logistic regression analysis was performed. RESULTS: UI was observed in 14.5% of patients (340/2346) at 3 months (95%CI 13-16%) and in 4.2% (98/2346) at 6 months (95%CI 3-5%). On multivariate analysis at 3 months, increasing age (OR per SD = 1.3 [1.14-1.48]), elevated BMI (OR per SD = 1.23 [1.09-1.38]), preoperative urinary drainage (OR = 0.62 [0.45-0.85]), increasing enucleated tissue weight (OR per SD = 1.29 [1.16-1.45]) and experienced surgeon with at least 40 cases (OR = 0.56 [0.42-0.75]) were significantly associated with UI. At 6 months, increasing age (OR per SD = 1.25 [1.01-1.53]), elevated BMI (OR per SD = 1.25 [1.03-1.5]), increasing whole gland volume (OR per one SD log = 1.24 [1.01-1.53]) and diabetes disorder (OR = 1.7 [1.03-2.78]) were significantly associated with UI. CONCLUSION: UI after HoLEP was observed in 14.5% of patients at 3 months and 4.2% at 6 months, with stress UI in half of the cases. Surgeon experience with at least 40 cases was the main predictive factor of 3 months UI after HoLEP and diabetes disorder of persistent UI at 6 months.

Observation vs. early drainage for grade IV blunt renal trauma: a multicenter study.

INTRODUCTION: The aim of this study was to compare observation and early drainage by ureteral stenting in patients with blunt renal trauma and urinary extravasation. MATERIALS AND METHODS: A retrospective national multicenter study was performed including all patients admitted for renal trauma at 17 hospitals between 2005 and 2015. Patients presenting with a urinary extravasation on initial imaging were considered for inclusion. Patients were divided in two groups according to the initial approach: observation vs. early drainage by ureteral stent (within 48 h after admission). The primary endpoint was the persistence of urinary extravasation on follow-up imaging. RESULTS: Out of 1799 patients with renal trauma, 238 were included in the analysis (57 in the early drainage and 181 in the observation group). In the early drainage group, 29 patients had persistent urinary extravasation vs. 77 in the observation group (50.9% vs. 42.5%; p value = 0.27). The rates of secondary upper urinary tract drainage did not differ significantly between the early drainage group (26.4%) and the observation group (16%) (p = 0.14). There were no statistically significant differences between the two groups in terms of secondary nephrectomy (0% vs. 2.8%; p = 0.34), and death from trauma (0% vs. 1.8%; p = 0.99). In multivariate analysis, early drainage remained not statistically associated with persistence of urinary extravasation on follow-up imaging (OR = 1.35; p = 0.36) CONCLUSION: In this multicenter cohort, observation was not different from early drainage in terms of persistent urinary extravasation after grade IV blunt renal trauma. Further randomized controlled prospective trials are needed to confirm these findings.

Early discharge in selected patients with low-grade renal trauma.

INTRODUCTION: The aim of this study was to assess whether early discharge could be non-inferior to inpatient management in selected patients with low-grade renal trauma (AAST grades 1-3). MATERIALS AND METHODS: A retrospective national multicenter study was conducted including all patients who presented with renal trauma at 17 hospitals between 2005 and 2015. Exclusion criteria were iatrogenic and AAST grades 4 and 5 trauma, non-conservative initial management, Hb < 10 g/dl or transfusion within the first 24 h, and patients with concomitant injuries. Patients were divided into two groups according to the length of hospital stay: ≤ 48 h (early discharge), and > 48 h (inpatient). The primary outcome was "Intervention" defined as any interventional procedure needed within the first 30 days. A Stabilized Inverse Probability of Treatment Weighting (SIPTW) propensity score based binary response model was used to estimate risk difference. RESULTS: Out of 1764 patients with renal trauma, 311 were included in the analysis (44 in the early discharge and 267 in the inpatient group). In the early discharge group, only one patient required an intervention within the first 30 days vs. 10 in the inpatient group (3.7% vs. 5.2%; p = 0.99). Adjusted analysis using SIPTW propensity score showed a risk difference of - 2.8% [- 9.3% to + 3.7%] of "interventions" between the two groups meeting the non-inferiority criteria. CONCLUSION: In a highly selected cohort, early discharge management of low-grade renal trauma was not associated with an increased risk of early "intervention" compared to inpatient management. Further prospective randomized controlled trials are needed to confirm these findings.

Correction to: Risk of biochemical recurrence based on extent and location of positive surgical margins after robot-assisted laparoscopic radical prostatectomy.

Following publication of the original article [1], we have been notified that the authors' last names have been incorrectly tagged as first names and vice-versa. The original publication has been corrected.

Risk of biochemical recurrence based on extent and location of positive surgical margins after robot-assisted laparoscopic radical prostatectomy.

BACKGROUND: There are no published studies on the simultaneous effect of extent and location of positive surgical margins (PSMs) on biochemical recurrence (BCR) after robot-assisted laparoscopic prostatectomy (RALP). The aim was to report the incidence, extent, and location of PSMs over the inclusion period as well as the rates of BCR and cancer-related mortality, and determine if BCR is associated with PSM extent and/or location. METHODS: Retrospective review of 530 consecutive patients who underwent RALP between 2003 and 2012. Kaplan-Meier (KM) survival analyses and Cox regressions were performed to determine variables associated with BCR. RESULTS: For the 530 operated patients, evaluated at a median of 92 months (IQR, 87-99), PSMs were observed in 156 (29%), of which 24% were focal. Out of 172 PSMs, 126 (73%) were focal and 46 (27%) were extensive. The KM survival using BCR as endpoint was 0.81 (CI, 0.78-0.85) at 5 years and was 0.67 (CI, 0.61-0.72) at 10 years; and using cancer-related mortality as endpoint was 0.99 (CI, 0.99-1.00) at 5 years and 0.95 (CI, 0.92-0.98) at 10 years. Multi-variable analysis revealed the strongest predictors of BCR to be Gleason score ≥ 8 (HR = 7.97; CI, 4.38-14.51) and 4 + 3 (HR = 3.88; CI, 2.12-7.07), lymph nodes invasion (HR = 3.42; CI, 1.70-6.91), pT stage 3b or 4 (HR = 3.07; CI, 1.93-4.90), and extensive apical PSMs (HR = 2.62; CI, 1.40-4.90) but not focal apical PSMs (HR = 0.86; CI, 0.49-1.50; p = 0.586). CONCLUSION: Extensive apical PSMs significantly increased the risk of BCR, independently from pT stage, Gleason score and lymph nodes invasion, while focal apical PSMs had no significant effect on BCR.

Intraoperative Cyst Rupture during Partial Nephrectomy for Cystic Renal Masses-Does it Increase the Risk of Recurrence?

PURPOSE: Our objective was to assess the prevalence of intraoperative cyst rupture and its impact on oncologic outcomes. MATERIALS AND METHODS: All patients who underwent partial nephrectomy for a cystic renal mass via an open or robot-assisted approach at a total of 8 academic institutions were included in this retrospective study. All operative reports were carefully reviewed and any description of cyst rupture, cyst effraction or local spillage intraoperatively was recorded as cyst rupture. Multivariate logistic regression analysis was done to assess the variables associated with cyst rupture. Recurrence-free, cancer specific and overall survival was estimated by the Kaplan-Meier method and compared with the log rank test. RESULTS: Overall 268 patients were included in study. There were 50 intraoperative cyst ruptures (18.7%) in the whole cohort. No preoperative parameter was significantly associated with a risk of intraoperative cyst rupture on univariate or multivariate analysis. Of the cystic renal masses 75% were malignant on the final pathology report. At a median followup of 32 months 5 patients (2.5%) had local recurrence while progression to metastasis was observed in 2%. There were no peritoneal carcinomatosis nor port site metastasis. There was also no local or metastatic recurrence in the subgroup with intraoperative cyst rupture. Estimated recurrence-free survival did not differ significantly between patients with vs without intraoperative cyst rupture at 100% vs 92.7% at 5 years (p = 0.20). CONCLUSIONS: Intraoperative cyst rupture during partial nephrectomy is a relatively common occurrence but with few oncologic implications.

Quantified analysis of histological components and architectural patterns of gleason grades in apparent diffusion coefficient restricted areas upon diffusion weighted MRI for peripheral or transition zone cancer locations.

PURPOSE: To quantify and compare the histological components and architectural patterns of Gleason grades in cancerous areas with restriction on apparent diffusion coefficient (ADC) maps. MATERIALS AND METHODS: Twelve consecutive cases with 14 separate ADC restriction areas, positive for cancer in the peripheral zone (PZ) and transition zone (TZ) were included. All had 3 Tesla MRI and radical prostatectomy. Ten regions of interest (ROIs) within and outside the 14 ADC restriction areas positive for cancer were selected. For each ROI, we performed quantitative analysis of (a) prostate benign and malignant histological component surface ratios, including stroma, glands, epithelium, lumen, cellular nuclei; (b) percent of Gleason grades and measures of ADC values. Means of histological components according to ADC restriction for cancerous area were compared with analyses of variance with repeated measures. RESULTS: Independent predictors of the probability of cancer were median epithelium/ROI ratio (P = 0.001) and nuclei/ROI ratio (P = 0.03). Independent predictors of the probability of ADC restriction were malignant glands/ROI and luminal space/ROI (P < 0.0001). Effect of malignant glands/ROI area was different according to the localization of the ROI (P = 0.03). We observed an overall difference between the means for all of the histological components for the comparison of true positive and false negative (P < 0.0001), except for the percent of Gleason grade 4 (P = 0.18). In TZ cancers, a predominant grade 3 pattern was associated with low ADC values. In PZ cancers, a predominant grade 4 pattern was associated with low ADC values. CONCLUSION: Determinants of low ADC were high ratio of malignant glands/ROI area which may be seen in Gleason grades 3 or 4 cancers. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1786-1796.

Robot-assisted laparoscopic approach for artificial urinary sphincter implantation in 11 women with urinary stress incontinence: surgical technique and initial experience.

BACKGROUND: Artificial urinary sphincter (AUS) implantation is recommended for women suffering urinary stress incontinence. Robot-assisted laparoscopy allows improved dexterity and visibility compared to traditional laparoscopy, potentially providing significant advantages for deep pelvic surgery. OBJECTIVE: To report our surgical technique and initial experience in transperitoneal robot-assisted laparoscopic AUS implantation in women with urinary stress incontinence. DESIGN, SETTING, AND PARTICIPANTS: Eleven eligible patients with AUS implantation or revision using robot-assisted laparoscopy for urinary stress incontinence were included between January 2012 and February 2014 at Department of Urology, Lille University Hospital. SURGICAL TECHNIQUE: Procedures were performed with the assistance of a four-arm da Vinci robot. The urethrovaginal space was dissected after transperitoneal access to the Retzius space. An 11-mm port placed in the right iliac fossa allowed introduction of the AUS device. The cuff and balloon tubes were externalised via a 5-mm suprapubic incision. The peritoneum was finally sutured. MEASUREMENTS: Clinical data were prospectively collected before, during, and after the procedure. Results were classified as complete continence (no leakage and no pad usage), social continence (leakage and/or pad usage with no impact on social life), or failure (leakage and/or pad usage impacting social life). RESULTS AND LIMITATIONS: After mean follow-up of 17.6 mo (interquartile range 10.8-26 mo), eight patients (72.7%) had a successful AUS implantation, of whom seven (87.5%) reported complete continence and one had social continence. Two vaginal injuries and two bladder injuries occurred intraoperatively. Two patients experienced early minor postoperative complications and two had a major postoperative complication. CONCLUSIONS: Robot-assisted laparoscopic AUS implantation is a feasible procedure. Further studies will better assess the place of robot-assisted laparoscopy in AUS implantation. PATIENT SUMMARY: We investigated the treatment of 11 patients with stress urinary incontinence using robot-assisted implantation of an artificial urinary sphincter (AUS). The results show that the procedure is feasible procedure, and future studies will to help assess the place of robot-assisted laparoscopy in AUS implantation.