Urinary Leakage after Robot-Assisted Radical Prostatectomy: Is Always Predictive of Functional Results?

INTRODUCTION: The aim of the study was to evaluate if and when the presence of radiological urinary leakages of vesico-urethral anastomosis, after robotic radical prostatectomy, could provoke urethral strictures or affect continence recovery. METHODS: We enrolled 216 patients, undergoing robot-assisted radical prostatectomy between January 2020 and December 2022 in three high-volume referenced centres for robotic surgery. Before removal of the bladder catheter, all patients underwent a cystourethrography in which the presence/absence of leakage was assessed at level of vesico-urethral anastomosis. Based on degree of severity of urinary leakage on cystourethrography, patients were classified as no leakage or grade 0, grade 1 with transversal diameter ≤1 cm, and grade 2 with transversal diameter ≥1 cm. At follow-up, urethral stenosis formation and urinary continence recovery were assessed; furthermore, post-operative 12-month functional outcome was determined using EORTC-QLQ-PR25 questionnaire. RESULTS: Radiological urinary leakage was found in 30 patients with grade 1 and 33 patients with grade 2, for a total of 63 patients. Only 1 patient (1.5%), grade 2 urinary leakage, developed significant urethral stricture and required endoscopic urethrotomy after 6 months. Analysing the differences in those who removed the bladder catheter after 7-9 days and those who kept it longer, we found no statistically significant differences regarding recovery of continence (p = 0.23) or about urinary symptoms (p = 0.94). CONCLUSIONS: RARP remains gold-standard approach for treatment of localized prostate cancer and the superiority of this technique is safe in preventing urethral strictures and continence recovery, even in presence of significant anastomotic urinary leakage.

Treatment of 2-4 cm kidney stones: multicentre experience. Comparison of safety, efficacy, and costs of percutaneous nephrolithotomy and retrograde intrarenal surgery.

Introduction: The objective of this study is to compare the safety and efficacy, through the stone-free rate (SFR), as well as the costs, between retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL), for 2-4 cm kidney stones. Material and methods: We analysed the data relating to RIRS and PCNL performed in 3 reference centres for kidney stones, in the period between 1/2019 and 12/2021. The total number of procedures was 130 (63 RIRS and 67 PCNL). We defined SFR as the absence of lithiasic fragments or stones <3 mm. Results were compared between 2 groups depending on the stone size: 2-3 cm stones (group 1) and >3 cm stones (group 2). Results: The duration of RIRS was 90 minutes for group 1 and 115 minutes for group 2, and for PCNL it was 135 minutes for group 1 and 145 minutes for group 2. RIRS had shorter duration with a significant difference in group 1 (p = 0.000014). SFR for RIRS was 78% for group 1 and 21% for group 2, and for PCNL it was 92% for group 1 and 81% for group 2. Therefore, there is a statistically significant difference, which is more evident for 3 cm and multiple stones (p = 0.0057 for group 1, p = 0.000146 for group 2). The difference in costs was estimated by calculating the expected costs for a single surgical procedure and the estimated cost per day for ordinary hospitalization. Conclusions: 2-4 cm stones can be safely treated with both RIRS and PCNL, but RIRS should not be chosen as an option for stones >3 cm, except in selected cases. PCNL remains the gold standard for the treatment of complex stones, especially for stones >3 cm. Risk of postoperative complications is higher in PCNL, even if this difference is not great. The costs associated with RIRS, even when recalculating with the need for new treatments, remain cheaper.

Impact of positive surgical margins (PSMs) after robotic prostatectomy on biochemical recurrence (BCR): Multicenter analysis.

OBJECTIVE: To study and analyze any correlations between positive surgical margins after RARP and biochemical recurrence. METHODS: We enrolled 105 patients who underwent robot-assisted radical prostatectomy (RARP) from 2016-2020 with PSMs on final pathology, all performed or supervised by a senior surgeon in two tertiary referral center. Pathology has been described indicating also the area (apical, base, mediolateral, anterior, or multiple) and the extent of PSMs: focal (≤3 mm) or extensive (>3 mm). Cox univariable and multi-variable regression models were used to find the correlation between clinico-pathologic factors: age, local staging, PSA, grading, area, and size of PSMs). RESULTS: We found a good correlation between PSA and grading and between PSA and local staging (T) (p < 0.001). There was no clear correlation between the PSM area with grading nor with T staging. There is a statistically significant correlation between extensive PSM and the worsening of grading and local staging (p < 0.001). BCR rate also has a strong correlation with the worsening of grading and local staging (T) (p < 0.001). A relevant fact is the difference between the BCR rate in the apical and base PSM (34.88%vs 62.5%; p < 0.001) which are the most frequent locations of PSMs. DISCUSSION: PSMs remain a predictor of BCR but which may have controversial significance. The likelihood of BCR increases as grading or local staging gets worse. However, apical PSM is a relatively less powerful predictor of postoperative BCR. This can help to better select patients for subsequent RT, which still causes important side effects.

Learning curve in robot-assisted partial nephrectomy: comparison between an expert surgeon and a team in training in single-center experiences.

INTRODUCTION: An important issue in robotic surgery is the training of urologists and the learning curve to perform a robot-assisted partial nephrectomy (RAPN), especially for those procedures that require vascular clamping. MATERIAL AND METHODS: We retrospectively enrolled 333 patients, undergoing RAPN in the period between 01/2014 and 12/2020. Surgical complexity, surgery duration, perioperative complications, and clamping were evaluated for each patient. Comparisons were made between an experienced surgeon and 3 urologists with initial experience in robotic surgery. RESULTS: Total number of RAPN was 333, of wich 172 were performed by the chief and 142 by the team. Analyzing the data, after an initial training in robotic surgery, it's possible to perform surgery of medium complexity (RENAL score 6-7) after 15 procedures performed in total independence. To proceed to high complexity tumors (RENAL score 8-9) with possible vascular clamping and warm ischemia time <25 minutes at least 25 completely independent procedures are required. There were no significant differences in the comparisons regarding the duration of the procedures (p = 0.19), complications (p = 0.44) and positive margins (p = 0.96). CONCLUSIONS: Robotic training for complex procedures, with low intra and postoperative complication rates, acceptable positive margin rates and sustainable cost-effective durations, requires a minimum number of medium complexity procedures, which in our study we have identified as 25 procedures, considering the initial ability in simple procedures of our 3 surgeons in training.

Molecular characterization of low grade and high grade bladder cancer.

BACKGROUND: Bladder cancer (BC) is the 9th most common cancer diagnosis worldwide. Low grade (LG) represents 70% of all BCs, characterized by recurrence and rare ability (10-15%) to progress to high grade (HG) and invade. The remaining 30% is high grade (HG), fast invasive BC, which is resistant to therapy. Identifying biomarkers for predicting those tumors able to progress is a key goal for patient outcome improvement. This study focuses on the most promising prognostic markers. MATERIALS AND METHODS: TP53 and FGFR3 mutational status, Survivin, CK19, CK20, E-cadherin and CD44 gene expression analysis were performed on 66 BCs. RESULTS: Survivin was found associated to tumor grade (p<0.05). Moreover, Survivin correlated with CD44 in TP53 wild type (p = 0.0242) and FGFR3 wild type (p = 0.0036) tumors. In particular the Survivin-CD44 correlation was associated to HG FGFR3 wild type BCs (p = 0.0045). Unsupervised hierarchical clustering based on gene expression data identified four distinct molecular groups reflecting the patient histology (p = 0.038). CONCLUSION: We suggest Survivin, both as a biomarker associated to G3 BCs but negatively related to TP53 mutational status, and as a potential novel therapeutic target.