Risk Factors for Persistent Lower Urinary Tract Symptoms 1 Month Following Convective Water Vapor Thermal Therapy (CWVTT-Rezum).

OBJECTIVE: To investigate the incidence and risk factors of persistent lower urinary tract symptoms (LUTS) 1 month and later following convective water vapor thermal therapy (CWVTT) in men with LUTS secondary to benign prostatic hyperplasia (BPH). METHODS: Patients who underwent CWVTT from 11/2018-5/2021 at a single institution were eligible for inclusion and retrospectively identified. Pertinent patient, operative, and outcomes data were extracted. The primary outcome was clinically significant LUTS improvement at 4 weeks following CWVTT. Persistent LUTS was defined as failure to reach a minimally clinical important difference of 25% reduction on International Prostate Symptom Score at 4 weeks. RESULTS: One hundred nine patients qualified. Fifty percent of patients experienced persistent LUTS at 1 month. Eighty-two percent of men ultimately reached the minimally clinical important difference. For each additional month following CWVTT, the odds of achieving clinically significant LUTS improved by 9% (Odds ratio (OR) = 0.91, P = .0033). Bladder outlet obstruction index and prior surgical BPH therapy were associated with persistent LUTS on multivariate logistic regression. Every 10-unit increase in Bladder outlet obstruction index noted at baseline was associated with a 15% increased likelihood of achieving minimally clinical important difference in LUTS at 4 weeks following CWVTT (OR = 0.85, P = .01). Patients receiving prior surgical BPH therapy were 3.5 times more likely to experience persistent LUTS at 1 month (OR = 3.47, P = .01). CONCLUSION: Fifty percent of men experienced persistent LUTS 1 month following CWVTT. However, LUTS improved with time and the majority of men ultimately achieved clinically significant LUTS improvement. A lower baseline Bladder outlet obstruction index and prior BPH procedures are risk factors for persistent LUTS following CWVTT.

Impact of median lobe on urinary function after robotic prostatectomy.

BACKGROUND: Enlarged median lobes (ML) can be technically challenging, particularly during bladder-neck dissection, and may affect urinary functional outcomes of robotic radical prostatectomy (RARP). If known, the impact of potentially larger bladder necks on continence and chronic obstruction on postoperative urinary symptoms might aid patient counseling. We assessed the impact of intraoperatively identified median lobes (ML) on urinary function. METHODS: We reviewed our prospective RP database from 2013 to 2020. AUA symptoms scores (AUA-SS) were assessed preoperatively and at 1, 3, and 6 months. We compared patients with and without ML (NoML). Bladder-neck sparing was routine to avoid reconstruction. RESULTS: Of 663 patients who completed AUA-SS questionnaires at all time points, 202 (30%) had ML. There were no significant differences in demographics, PSA, or clinical stage. Only two patients in ML and one in NoML group required bladder-neck reconstruction (1.2% and 0.2%). There was no immediate or long-term difference in continence rates between groups. Baseline mean AUA-SS was higher in ML patients and showed more improvement postoperatively (-5.5 vs. -3.6, p < .05) with greatest improvement in ML patients with severe preoperative symptoms (-15.1). There was no difference in AUA-SS between groups by 6 months. CONCLUSIONS: The presence of enlarged ML does not increase the risk of incontinence after RARP and it appears that ML patients have greater improvements in postsurgical urinary functions. Preoperative diagnosis of ML and lower urinary tract symptoms assessment could be helpful in counseling patients undergoing RARP regarding their expected postoperative urinary outcomes.

Impact of Surgeon-Controlled Suction During Robotic Prostatectomy to Reduce Dependence on Bedside Assistance.

Background: Suction during robotic surgery has traditionally been performed by a bedside assistant. Adequately skilled assistants are not always available. We assessed a purpose-designed robotic surgeon-controlled suction catheter for efficiency and safety by comparing with historic cases of suction controlled by a dedicated bedside assistant using standard rigid laparoscopic suction. Methods: Beginning in February 2019, the remotely operated suction irrigation (ROSI) device was used in all robotic prostatectomy procedures, which is a flexible suction catheter manipulated by the surgeon such that a bedside assistant is never required for suction. The initial 300 consecutive cases performed with ROSI were compared with the 300 immediately previous procedures using bedside assistant suction (BAS). Results: There were no statistically significant differences between groups in age, body mass index, American Anesthesiologist Association score, prostate specific antigen, or pathologic stage. Lymph node dissection was performed in all 600 patients. All 300 ROSI cases were completed without requiring switching to BAS. Estimated blood loss (102.7 vs 120.2 mL, p = 0.001) and operative time (156.1 vs 149.3 minutes, p < 0.001) were slightly lower in the ROSI group. There was no statistical difference in the 90-day complication rate (Clavien ≥III) between groups, with both having 3% of patients readmitted or seen in the emergency department within 90 days of surgery. Conclusion: Surgeon-controlled suction allowed more surgeon autonomy without a negative impact on efficiency or safety issues requiring "bailout" suctioning by the bedside assistant whether urgent or otherwise. Robotic surgeons without access to skilled bedside assistants should consider suctioning for themselves not unlike the norm for many laparoscopic surgeons.

Single-port Robotic Surgery Allows Same-day Discharge in Majority of Cases.

OBJECTIVE: To assess the influence of single-port (SP) robotic surgery on length of stay (LOS) in our initial experience using the da Vinci SP robot as compared with traditional, multiport procedures. METHODS: We evaluated our single surgeon (RA) prospective database for the initial 100 SP procedures performed between January 2019 and January 2020. Patient LOS was compared with standard multiport robotic surgery patients since we began routinely offering same-day discharge (SDD) in September 2016. RESULTS: Among the initial 100 SP robotic surgeries, there were 59 prostatectomies, 18 partial nephrectomies, 12 pyeloplasties, 4 nephrectomies, 4 adrenalectomies, 2 partial cystectomies, and 1 nephroureterectomy. The rate of SDD in SP procedures was higher compared to our historical SDD for multiport robotic surgeries despite uniformly offering SDD to all patients in both groups (88% vs 51%, P < .0001). Among prostatectomies, 88% of SP patients were discharged the same day versus 55% (P < .001). Among partial nephrectomies, 83% of SP patients went home the same day versus 17% (P < .001) as well as 83% of pyeloplasty patients versus 52% (P = .064). For SP adrenalectomy, nephrectomy, partial cystectomy, and nephroureterectomy, all were discharged the same day. CONCLUSION: Our initial experience with SP robotic surgery suggests earlier discharge is possible with the large majority (88%) so far opting to go home the same day as surgery. Further experience will be necessary to allow analysis of pain scores and analgesic usage as potential causative factors.

Same Day Discharge after Robotic Radical Prostatectomy.

PURPOSE: The typical mean length of stay following robot-assisted laparoscopic prostatectomy is 24 to 48 hours. We began routinely offering same day discharge from the hospital after robot-assisted laparoscopic prostatectomy. We evaluated the success rate, safety and cost implications in what is to our knowledge the only large series of same day discharge to date. MATERIALS AND METHODS: Beginning in September 2016 all patients were given the option of same day discharge without it being mandated. After allowing 3 months to solidify the protocol we evaluated our prospective database for the next 500 patients. RESULTS: Of the 500 consecutive men who underwent robot-assisted laparoscopic prostatectomy performed by 1 surgeon in 18 months 246 (49.2%) were discharged home the day of surgery and all of the remaining 254 were discharged the next day for a mean 0.51-day length of stay. Mean patient age was 62 years (range 42 to 81) and mean body mass index was 29.7 kg/m2 (range 20 to 53). Of the patients 34 (6.8%) had a Clavien-Dindo grade I-III complication within 90 days but there were no grade IV-V complications. Only 5 patients (1%) required an emergency department visit and only 8 (1.6%) required readmission. Only 1 of the patients who elected same day discharge was rehospitalized and only 1 presented to the emergency department. The estimated charge for an overnight stay at our institution is $2,109. The approximate reduction in charges was $518,814 during 18 months ($345,876 per year) with no increased cost due to emergency department visits or hospital readmissions compared with that of overnight patients. In the most recent 100 patients the rate of same day discharge improved to 65%. CONCLUSIONS: Same day discharge following robot-assisted laparoscopic prostatectomy can be safely routinely offered with no increase in readmissions or emergency visits. It may lead to significant savings in health care costs.