Perioperative and functional outcomes following robot-assisted partial nephrectomy: Descriptive analysis of Indian study group on partial nephrectomy database.

Introduction: There is an unmet need for high-quality data for Robot-assisted partial nephrectomy (RAPN) in the Indian population. Indian study group on partial nephrectomy (ISGPN) is a consortium of Indian centers contributing to the partial nephrectomy (PN) database. The current study is a descriptive analysis of perioperative and functional outcomes following RAPN. Methods: For this study, the retrospective ISGPN database was reviewed, which included patients who underwent RAPN for renal masses at 14 centers across India from September 2010 to September 2022. Demographic, clinical, radiological, perioperative, and functional data were collected and analyzed. Ethics approval was obtained from each of the participating centers. Results: In this study, 782 patients were included, and 69.7% were male. The median age was 53 years (interquartile range [IQR 44-62]), median operative time was 180 min (IQR 133-240), median estimated blood loss was 100 mL (IQR 50-200), mean warm ischemia time was 22.7 min and positive surgical margin rates were 2.5%. The complication rate was 16.2%, and most of them were of minor grade. Trifecta and pentafecta outcomes were attained in 61.4% and 60% of patients, respectively. Conclusions: This is the largest Indian multi-centric study using the Indian Robotic PN Collaborative database to evaluate the outcomes of robot-assisted PN, and has proven its safety and efficacy in the management of renal masses.

Fumarate hydratase-deficient renal cell carcinoma: an oncology care institutional experience.

Renal cell carcinoma (RCC) accounts for 2% of all cancer cases worldwide, and majority are sporadic. The latest World Health Organization (WHO) classification of renal cell tumors (fifth edition, 2022) has molecularly defined renal tumor entities, which includes fumarate hydratase (FH)-deficient RCC. FH-deficient RCC is an aggressive carcinoma caused by pathogenic alterations in FH gene, seen in 15% of patients with hereditary leiomyomatosis and renal cell cancer syndrome (HLRCC) syndrome. These tumors occur more frequently at a younger age and present at an advanced stage, carrying a dismal prognosis. We report a series of 10 cases of FH-deficient RCC. The mean age was 49.8 years, and all cases presented in advanced stages (III and IV). Morphologically, the cases had varied architectural patterns with characteristic eosinophilic macronucleoli and perinucleolar halo. On immunohistochemistry (IHC), all showed diffuse nucleo-cytoplasmic expression of S-(2-succino)-cysteine (2-SC), with loss of FH in seven cases. FH-deficient RCCs are aggressive neoplasms and can be diagnosed using specific IHC markers (FH and 2-SC). These patients should undergo germline testing for FH gene mutation, genetic counseling, and surveillance of family members.

Robot-Assisted Video Endoscopic Inguinal Lymph Node Dissection for Penile Cancer: An Indian Multicenter Experience.

Objective: To report outcomes of multicenter series of penile cancer patients undergoing robot-assisted video endoscopic inguinal lymph node dissection (RA-VEIL). Materials and Methods: In this retrospective analysis from 3 tertiary care centers in India, consecutive intermediate-/high-risk carcinoma penis (CaP) patients with nonpalpable inguinal lymphadenopathy and/or nonbulky (<3 cm) mobile inguinal lymphadenopathy undergoing RA-VEIL were included. Patients with matted/bulky (>3 cm) and fixed lymphadenopathy were excluded. Demographic, clinical, and intraoperative data were recorded. Perioperative complications were graded by the Clavien-Dindo classification (CDC). The International Society of Lymphology (ISL) {0-III} grading was used for the assessment of lymphedema. Incidence and pattern of recurrences were assessed on follow-up. Results: From January 1, 2011, to September 30, 2023, 115 patients (230 groins) underwent bilateral RA-VEIL for CaP. The median age of the cohort was 60 (50-69) years. Clinically palpable (either unilateral or bilateral) inguinal lymphadenopathy was seen in 54 patients (47%). The "per groin" median operative time was 120 (100-140) minutes with median lymph node yield of 12 (9-16). No complications were recorded in 87.8% groins operated, with major complications (CDC 3) seen in 2.6% groins. At a median follow-up of 13.5 months, 13 patients had documented recurrences and there were 10 cancer-related deaths. No port-site recurrences were observed. No/minimal lymphedema (ISL 0/I) was seen in 94% legs. Conclusion: RA-VEIL demonstrates safety and oncologic efficacy in penile cancer patients presenting with clinically nonpalpable and/or nonbulky inguinal lymphadenopathy, with favorable functional outcomes.

Surgical and oncological outcomes of robot-assisted versus laparoscopic radical nephroureterectomy for upper-tract urothelial carcinoma: A single-center comparative analysis.

Introduction: We retrospectively compared surgical and oncological outcomes of robot-assisted (RA) radical nephroureterectomy (RNU) in patients of upper-tract urothelial carcinoma with a cohort of patients who underwent the same procedure using a laparoscopic approach. Methods: Data of 63 consecutive patients who underwent RNU with bladder cuff excision (BCE) from 2011 to 2022 at a single tertiary care institution was retrospectively retrieved from the electronically maintained institutional database. Twenty-six cases underwent RNU with a laparoscopic approach, whereas 37 were done by RA approach. Demographic, clinical, surgical, and pathologic details and survival analyses were reported and compared. The tetrafecta of RNU, which include the performance of a BCE, lymphadenectomy, no positive surgical margin, and no major surgical complication, was also reviewed. Results: The mean age and body mass index of the robotic and laparoscopic groups were 61.5 years versus 62.7 years and 23.8 versus 24.9 kg/m2, respectively (P = 0.710 and 0.309). The Charlson Comorbidity Index and upper-tract tumor site distribution were comparable between the groups. There was no significant difference in the distribution of T stage, N stage, presence of multifocality, or lymphovascular invasion between the two groups. Although the rate of concomitant carcinoma in situ was higher in laparoscopic cohort, 42.8% versus 10.8% in robotic cohort (P = 0.004). The laparoscopic group had higher blood transfusion rates (50 vs. 13.5%, P = 0.002) and longer median hospital stays (7 vs. 4 days, P = 0.000). The median follow-up time was 21.5 versus 27 months in the laparoscopic and robotic groups. The RA group was significantly better in the achievement of the tetrafecta outcomes. The 5-year urinary bladder recurrence-free survival (UB RFS) and elsewhere RFS between the laparoscopic and robotic cohorts were 65% versus 72% and 56% versus 70%, respectively (P = 0.510 and 0.190). The laparoscopic cohort had worse 5-year cancer-specific survival and overall survival (64% vs. 90% and 58% vs. 74%, P = 0.04 and 0.08). Conclusion: The robotic approach to RNU and BCE has significantly lower transfusion rates, lower hospital stays, and significantly better cancer-specific survival rates.

Prostate cancer detection using magnetic resonance imaging-transrectal ultrasound fusion biopsy: A retrospective cohort study.

Introduction: Transrectal ultrasound (TRUS) guided systematic prostate biopsy is conventionally used for the diagnosis of carcinoma prostate (CaP). However, magnetic resonance imaging (MRI) guided biopsies have been shown to have superior diagnostic performance. MRI-TRUS fusion biopsy improves the detection by combining the systematic and the targeted biopsies (TB). In this study, we evaluated the role of fusion biopsy in the detection of CaP as well as clinically significant carcinoma prostate (CsCaP). Methods: In this retrospective study, the patients who underwent fusion biopsy from January 2016 to July 2022 were evaluated. Patients underwent multiparametric MRI and the suspicious lesions were reported as per the Prostate Imaging Reporting and Data System (PIRADS) version 2. The clinical, imaging, and biopsy parameters were recorded and evaluated. Results: A total of 330 patients with PIRADS ≥3 underwent MRI-TRUS fusion biopsy and prostate cancer was detected in 187 patients (56.67%). With an increase in the PIRADS score, there was a significant rise in the detection of CaP (P < 0.001) and CsCaP (P < 0.0000001). Prostatitis was observed in 13%-18.1% of the patients with a lesion on MRI irrespective of the PIRADS score. The systematic and TB were comparable for the detection of CaP (P = 0.88) and CsCaP (P = 0.26). With a prostate-specific antigen density (PSAD) cutoff of 0.15 ng/mL/cc and 0.22 ng/mL/cc, biopsy could be safely avoided in 14.2% and 20.3% of the patients, missing only 0.3% of CaP and 0.9% of CsCaP, respectively. Different subgroups based on PSA levels, prostate volume, lesion dimension, and PIRADS score did not show a significant difference between the systematic and the targeted cores for the detection of CsCaP. Conclusion: This single center study of MRI-TRUS fusion prostate biopsy shows that in men with clinical suspicion of prostate cancer a pre-biopsy MRI and MRI-TRUS fusion combined systematic and targeted prostate biopsy improves the detection of prostate cancer and CsCaP. Patients with a PIRADS 3 lesion with a PSA density <0.22 can safely avoid prostate biopsy, without a significant risk of missing clinically significant prostate cancer.

Cutaneous Radiation-Associated Angiosarcoma After Treatment of Carcinoma Penis: First Report from Tertiary Cancer Centre of North India.

Cutaneous radiation-associated angiosarcoma (cRAA) is a rare and aggressive secondary cutaneous angiosarcoma (cAS) with poor survival. cRAA has been mostly reported in breast carcinoma patients. Owing to its rarity, there is scanty literature available and no treatment guidelines. To the best of our knowledge, this is the first report of cRAA after multimodality treatment of carcinoma penis. A sixty-eight-year-old gentleman, a known case of carcinoma penis, underwent total penectomy with perineal urethrostomy and bilateral radical inguinopelvic lymph node dissection 6 years ago. He received adjuvant radiotherapy to the pelvis and bilateral groin. He presented with a bleeding plaque-like lesion with ulceration over the left lower abdomen (within previous radiation field) which rapidly progressed in size over the past 2 months. On examination, the lesion bled profusely on touch. Contrast MRI was suggestive of lobulated exophytic enhancing cutaneous lesion free from underlying muscle. Wedge biopsy was suggestive of cutaneous angiosarcoma. He underwent wide local excision with local perforator flap reconstruction from the right lower abdomen. Histopathology was suggestive of cutaneous angiosarcoma which showed immunoexpression of CD31, ERG1, cMYC suggestive of cRAA. cRAA is a very aggressive disease with 5-year survival of 15-34%. To the best of our knowledge, this is the first ever reported case of cRAA of lower abdomen after multimodality management of carcinoma penis. It masquerades with other benign and less aggressive radiation-induced skin lesions. cMYC immunoexpression is specific for secondary cAS. Wide local resection with negative margin provides the best outcome.

Enzalutamide-Induced Acute Maculopapular Rash in Treatment of Metastatic Prostate Cancer: First Case Report from a Tertiary Cancer Care Center of North India.

Enzalutamide is a new potent inhibitor of the signaling pathway for the androgen receptor with a half-life of 5.8 days. It has been on the market for the treatment of metastatic castration-resistant prostate cancer since November 2013. We report a case of acute generalized exanthematous maculopapular rash induced by enzalutamide. In summary, newer androgen receptor blockers have a propensity to cause skin related adverse effects. Most common among these are apalutamide. Enzalumatamide, per se, is a safe drug and has not been associated frequently in causing maculopapular rash. Few cases has been reported. In all these cases, the drug was discontinued and 2nd line therapy was instituted. In this report, Enzalutamide was withheld for 10 days and anti-histaminics was instituted. After a full recovery, Enzalutamide was reinstituted in treatment. A 62-year-old male patient with no significant medical history, was diagnosed in March 2020 with metastatic prostatic adenocarcinoma. Baseline PSA was 456 ng/ml. PSMA PET scan showed evidence of multiple bony metastasis. He was started on Degarelix subcutaneous injection with oral abiraterone initially. PSA level showed initial decreasing trend till September 2021 followed by sudden increase. Intramuscular Injection leuprolide was started and initial responses were good followed by later rise of PSA from January. Tab Xtandi (Enzalutamide) was added to the regimen from 31.1.22. Three days after starting enzalutamide treatment, the patient experienced an acute skin reaction. It is about of the plaques covered with widespread millimetric non-follicular papules. Enzalutamide was stopped after appearance of rashes to avoid further serious adverse effects. Anti-histaminics were started. Complete resolution of skin lesions occurred within 10 days. Tab Enzalutamide was reinstituted on 11th day after stoppage and on complete resolution of skin resolutions. According to the CTCAE 5.0 criteria, these skin rash was graded as grade 2. In view of evidence in literature and clinical improvement after stoppage, the acute drug reaction was attributed to enzalutamide. Uro oncologist can be confronted with adverse skin drug reactions attributable to new therapeutic molecules. The slow resolution of symptoms seems be due to the long half-life of enzalutamide. It should not be withdrawn from therapy owing to these effects. Rather, it should be with stopped for 10-14 days. Basic treatment with anti-histaminics or topical steroids may be enough to warranty the resolution of symptoms, and the drug (Enzalutamide) can be continued thereafter.

IgG4-related retroperitoneal fibrosis: A case report of a challenging disease.

Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a multi-organ immune-mediated fibroinflammatory disorder that may imitate malignancy, infectious or any other inflammatory disorder. IgG4-related retroperitoneal fibrosis (IgG4-RPF) is a rare form of IgG4-RD, diagnosis of which is often relied on radiological technology. Herein, we describe a case of 60 year old male, presenting with low back pain and weight loss for a period of 2 months and 15 days. Imaging studies showed a retroperitoneal tumorous mass along with bilateral hydroureteronephrosis, which was later confirmed to be IgG4-related retroperitoneal fibrosis on the basis of extensive histopathological analysis. Immunosuppressive therapy resulted in a decrease in fibrosis and restoration of renal function.

Off-clamp Versus On-clamp Robot-assisted Partial Nephrectomy: A Propensity-matched Analysis.

BACKGROUND: Partial nephrectomy is the preferred treatment option for the management of small renal masses. On-clamp partial nephrectomy is associated with a risk of ischemia and a greater loss of postoperative renal function, while the off-clamp procedure decreases the duration of renal ischemia, leading to better renal function preservation. However, the efficacy of the off- versus on-clamp partial nephrectomy for renal function preservation remains debatable. OBJECTIVE: To compare perioperative and functional outcomes following off- and on-clamp robot-assisted partial nephrectomy (RAPN). DESIGN, SETTING, AND PARTICIPANTS: This study used the prospective multinational collaborative Vattikuti Collective Quality Initiative (VCQI) database for RAPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary objective of this study was the comparison of perioperative and functional outcomes between patients who underwent off- and on-clamp RAPN. Propensity scores were calculated for age, sex, body mass index (BMI), renal nephrometry score (RNS) and preoperative estimated glomerular filtration rate (eGFR). RESULTS AND LIMITATIONS: Of the 2114 patients, 210 had undergone off-clamp RAPN and others on-clamp procedure. Propensity matching was possible for 205 patients in a 1:1 ratio. After matching, the two groups were comparable for age, sex, BMI, tumor size, multifocality, tumor side, face of tumor, RNS, polar location of the tumor, surgical access, and preoperative hemoglobin, creatinine, and eGFR. There was no difference between the two groups for intraoperative (4.8% vs 5.3%, p = 0.823) and postoperative (11.2% vs 8.3%, p = 0.318) complications. Need for blood transfusion (2.9% vs 0, p = 0.030) and conversion to radical nephrectomy (10.2% vs 1%, p < 0.001) were significantly higher in the off-clamp group. At the last follow-up, there was no difference between the two groups for creatinine and eGFR. The mean fall in eGFR at the last follow-up compared with that at baseline was equivalent between the two groups (-16.0 vs -17.3 ml/min, p = 0.985). CONCLUSIONS: Off-clamp RAPN does not result in better renal functional preservation. Alternatively, it may be associated with increased rates of conversion to radical nephrectomy and need for blood transfusion. PATIENT SUMMARY: With this multicentric study, we noted that performing robotic partial nephrectomy without clamping the blood supply to the kidney is not associated with better preservation of renal function. However, off-clamp partial nephrectomy is associated with increased rates of conversion to radical nephrectomy and blood transfusion.

Robot-assisted partial nephrectomy in morbidly obese patients: a VCQI database study.

To compare perioperative outcomes following robot-assisted partial nephrectomy (RAPN) in patients with morbid obesity (body mass index (BMI > 40 kg/m2)) and non-obese patients. Using the Vattikuti Collective quality initiative (VCQI) database for RAPN, data for morbidly obese and non-obese patients was obtained. Propensity scores were calculated for two treatment groups (morbidly obese vs. non-obese) for the following variables i.e. age, sex, tumor size, RNS, surgical access (retroperitoneal/transperitoneal) and estimated glomerular filtration rate (eGFR) to ensure comparability. The primary outcome for the study was comparison of trifecta between the two groups. In this study, 158 morbidly obese patients were matched with 158 non-obese patients undergoing RAPN. Two groups matched well for age, sex, tumor size, eGFR and RNS. There was no difference between two groups for ischemia time, blood loss, blood transfusion, conversion to radical nephrectomy, length of stay, intraoperative and postoperative complications. Operative time was longer in morbidly obese patients (median 210 min vs. 120 min, p = 0.000). On pathological analysis, malignant tumors were more likely in the morbidly obese group (83.1% vs.73.4%, p = 0.018). Trifecta outcomes were comparable between the two groups (60.1% vs. 63.3%, p = 0.563). The Median duration of follow-up was 12 months (1-96 months). The morbidly obese group had significantly higher day one creatinine (1.25 ± 0.7 vs. 1.07 ± 0.37, p = 0.001) and significantly lower day one eGFR (62.1 ± 19 vs. 69.2 ± 21, p = 0.018). However, there was no difference between the two groups for the last follow-up creatinine and eGFR. RAPN in morbidly obese patients is associated with equivalent perioperative outcomes compared to non-obese patients.

Trifecta and pentafecta outcomes following robot-assisted partial nephrectomy in a multi-institutional cohort of Indian patients.

Introduction: The literature on studies reporting trifecta or pentafecta outcomes following robot-assisted partial nephrectomy (RAPN) in Indian patients is limited. The primary aim of this study was to report and evaluate the factors predicting trifecta and pentafecta outcomes following RAPN in Indian patients using the multicentric Vattikuti collective quality initiative (VCQI) database. Methods: From the VCQI database for patients who underwent RAPN, data for Indian patients were extracted and analyzed for factors predicting the achievement of trifecta and pentafecta following RAPN. Trifecta was defined as the absence of complications, negative surgical margins, and warm ischemia period shorter than 25 min or zero ischemia. Pentafecta covers all the trifecta criteria as well as >90% preservation of estimated glomerular filtration rate (eGFR) and no stage upgrade of chronic kidney disease at 12 months. Results: In this study, among 614 patients, the trifecta was achieved in 374 patients (60.9%) and pentafecta was achieved in 24.2% of the patients. Patients who achieved trifecta had significantly higher mean age (54.1 vs. 51.0 years, P = 0.005), body mass index (BMI) (26.7 vs. 26.03 kg/m2, P = 0.022), and smaller tumor size (38.6 vs. 41.4 mm, P = 0.028). The preoperative eGFR (84.2 vs. 91.9 ml/min, P = 0.012) and renal nephrometry score (RNS) (6.96 vs. 7.87, P ≤ 0.0001) were significantly lower in the trifecta group. Comparing patients who achieved pentafecta to those who did not, we noted a statistically significant difference between the two groups for tumor size (36.1 vs. 41.5 mm, P = 0.017) and RNS (6.6 vs. 7.7, P = 0.0001). On multivariate analysis, BMI and RNS were associated with trifecta outcomes. Similarly, only RNS was identified as an independent predictor of pentafecta. Conclusions: RNS and BMI were independent predictors of the trifecta. At the same time, RNS was identified as an independent predictor of pentafecta following RAPN.

Robot-assisted retroperitoneal lymph node dissection for post-chemotherapy residual mass in testicular cancer: Long-term experience from a tertiary care centre.

Objectives: To present our intermediate to long-term oncological and functional outcomes of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in post-chemotherapy (PC) residual mass in testicular cancers. To the best of our knowledge, this is the largest single-centre experience of RA-RPLND for in such setting. Methods: Prospectively maintained database of carcinoma testis patients undergoing RA-RPLND from February 2012 to September 2021 was reviewed. Patient demographics, tumour stage and risk groups and chemotherapy details were recorded. Intraoperative details and post-operative complications were also noted. Pathological outcomes included were lymph node yield and histopathology report. Further, follow-up was done for recurrence and antegrade ejaculation status. Results: Total of 37 cases were done for PC residual masses. International germ cell cancer collaborative group good, intermediate and poor risk proportion was 18 (48.6%), 14 (37.8%) and 5 (13.5%), respectively. Bilateral full template dissection, unilateral modified template dissection and residual mass excision was performed in 59.5% (22/37), 35.1% (13/37) and 5.4% (2/37) patients, respectively. The median size of the excised residual mass was 3.45 cm interquartile range (IQR 2-6 cm), with the largest being 9 cm. The median lymph nodal yield was 19. The most common histology was necrosis (n = 24, 65%), followed by teratoma (n = 11, 30%) and viable malignancy (n = 2, 5%). Antegrade ejaculation was reported in 32 patients (86.4%). After a median follow-up of 41 (IQR 14-64) months, only one patient had a recurrence. Conclusions: RA-PC-RPLND is thus a safe, feasible and oncologically effective option for selected patients. With increasing experience, larger masses can also be dealt with efficiently.

Inguinal lymph node dissection in the era of minimally invasive surgical technology.

BACKGROUND: Inguinal lymph node dissection (ILND) is an essential step in both treatment and staging of several malignancies including penile and vulvar cancers. Various open, video endoscopic, and robotic-assisted techniques have been utilized so far. In this review, we aim to describe available minimally invasive surgical approaches for ILND, and review their outcomes and complications. METHODS: The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000-2020. FINDINGS: There are different minimally invasive platforms available to accomplish dissection of inguinal nodes without jeopardizing oncological results while minimizing postoperative complications. Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy are safe and achieve the same nodal yield, a surrogate metric for oncological adequacy. When compared to open technique, Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy may offer faster postoperative recovery and fewer postoperative complications including wound dehiscence, necrosis, and infection. The relatively high rate and severity of postoperative complications hinders utilization of recommended ILND for oncologic indications. Minimally invasive approaches, using laparoscopic or robotic-assisted platforms, show some promise in reducing the morbidity of this procedure while achieving adequate short and intermediate term oncological outcomes.

Development and Validation of a Nomogram Predicting Intraoperative Adverse Events During Robot-assisted Partial Nephrectomy.

BACKGROUND: Ability to predict the risk of intraoperative adverse events (IOAEs) for patients undergoing partial nephrectomy (PN) can be of great clinical significance. OBJECTIVE: To develop and internally validate a preoperative nomogram predicting IOAEs for robot-assisted PN (RAPN). DESIGN, SETTING, AND PARTICIPANTS: In this observational study, data for demographic, preoperative, and postoperative variables for patients who underwent RAPN were extracted from the Vattikuti Collective Quality Initiative (VCQI) database. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: IOAEs were defined as the occurrence of intraoperative surgical complications, blood transfusion, or conversion to open surgery/radical nephrectomy. Backward stepwise logistic regression analysis was used to identify predictors of IOAEs. The nomogram was validated using bootstrapping, the area under the receiver operating characteristic curve (AUC), and the goodness of fit. Decision curve analysis (DCA) was used to determine the clinical utility of the model. RESULTS AND LIMITATIONS: Among the 2114 patients in the study cohort, IOAEs were noted in 158 (7.5%). Multivariable analysis identified five variables as independent predictors of IOAEs: RENAL nephrometry score (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.25); clinical tumor size (OR 1.01, 95% CI 1.001-1.024); PN indication as absolute versus elective (OR 3.9, 95% CI 2.6-5.7) and relative versus elective (OR 4.2, 95% CI 2.2-8); Charlson comorbidity index (OR 1.17, 95% CI 1.05-1.30); and multifocal tumors (OR 8.8, 95% CI 5.4-14.1). A nomogram was developed using these five variables. The model was internally valid on bootstrapping and goodness of fit. The AUC estimated was 0.76 (95% CI 0.72-0.80). DCA revealed that the model was clinically useful at threshold probabilities >5%. Limitations include the lack of external validation and selection bias. CONCLUSIONS: We developed and internally validated a nomogram predicting IOAEs during RAPN. PATIENT SUMMARY: We developed a preoperative model than can predict complications that might occur during robotic surgery for partial removal of a kidney. Tests showed that our model is fairly accurate and it could be useful in identifying patients with kidney cancer for whom this type of surgery is suitable.

Robotic re-exploration for post-operative in house complications following robotic pelvic uro-oncologic surgery: Initial experience, tips and tricks.

Purpose: Despite widespread acceptance of robotics in urology, literature on using the minimally invasive approach for management of post robotic surgical complications is limited. Here we describe our experience with tips and tricks for robotic re-exploration of post-operative in house complications following robotic pelvic uro-oncologic surgery. Methods: A retrospective query of prospectively maintained database was done for all patients who underwent robotic - radical cystoprostatectomy (RCP, 437 patients) and radical prostatectomy (RP, 649 patients), from Jan 2015 or March 2021. Clinical details were collected for all who underwent a second robotic procedure during the same hospital admission for any complication related to the primary surgery. Results: Following RCP, 5 patients were re-explored for intestinal obstruction. Surgery was successfully completed in all with a median console time of 80 minutes. Median time to the passage of flatus and discharge from hospital following relook surgery was 3 and 6 days, respectively. Following RP, 3 patients underwent robotic re-exploration (two for reactionary hemorrhage, one for rectal injury). All three cases were managed with a median console time of 75 minutes. Robotic re-exploration was accomplished without extending the skin incision of the index surgery and we did not find an increased incidence of infectious or wound related complications. Conclusion: Robotic re-exploration for select post robotic urologic pelvic oncology surgery complications in the immediate and early post-operative period is feasible in the hands of experienced surgeons. Our experience can help others adopt robotics in such scenarios.

Single Institute Experience with Neo-Adjuvant Chemotherapy and Interval Debulking Surgery in Advanced Endometrial Cancer.

Our study aims to review the role of neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) in patients with advanced endometrial cancer. Patients with advanced endometrial cancer treated with NACT followed by IDS at our institute from January 2010 to January 2020 were recruited. Data pertaining to baseline patient characteristics, surgical details, histopathology/imaging reports, treatment and follow up details including the development of recurrence and death were collected from institutional database. Disease free survival (DFS) and overall survival (OS) were calculated using Kaplan Meier survival curves. We recruited 31 patients for our study. About 83.9% patients showed partial response and 6.4% patients responded completely to NACT with none of the patients developing disease progression. Complete cytoreduction was achieved in 90.3% patients, optimal cytoreduction in 3.2% patients while 6.5% patients had suboptimal surgery. On completion of primary treatment, complete remission was achieved by 80.6% patients while 16.1% patients had progressive disease. Median follow up period was 21 months (range 1- 61 months). During follow up period, 51.6% patients developed recurrent disease after achieving complete remission and 61.3% patients died of disease progression/recurrence. The median DFS and median OS of the cohort was 15 months and 21 months respectively. The 2 year DFS for the cohort was 34.1% and the 3 year OS was 30.5%. NACT followed by IDS is a reasonably good option for advanced stage endometrial cancer not amenable to primary surgery. Innovative treatments are warranted in this cluster of patients.

2/1 dose schedule of sunitinib is superior than the 4/2 regimen for the first-line therapy of clear cell metastatic renal cell carcinoma - An Indian experience.

BACKGROUND: Sunitinib remains the first-line treatment for favorable risk metastatic clear cell renal cell cancer (mccRCC). It was conventionally given in the 4/2 schedule; however, toxicity necessitated trying the 2/1 regimen. Regional variations in treatment response and toxicity are known, and there is no data from the Indian subcontinent about the outcomes of the alternative dosing schedule. METHODS: Clinical records of all consecutive adult patients who received sunitinib as first-line therapy for histologically proven mccRCC following cytoreductive nephrectomy from 2010-2018 were reviewed. The primary objective was to determine the progression-free survival (PFS), and the secondary objectives were to evaluate the response rate (objective response rate and clinical benefit rate), toxicity, and overall survival. A list of variables having a biologically plausible association with outcome was drawn and multivariate inverse probability treatment weights (IPTW) analysis was done to determine the absolute effect size of dosing schedules on PFS in terms of "average treatment effect on the treated" and "potential outcome mean." RESULTS: We found 2/1 schedule to be independently associated with higher PFS on IPTW analysis such that if every patient in the subpopulation received sunitinib by the 2/1 schedule, the average time to progression was estimated to be higher by 6.1 months than the 4/2 schedule. We also found 2/1 group to have a lower incidence than the 4/2 group for nearly all ≥ grade 3 adverse effects. Other secondary outcomes were comparable between both treatment groups. CONCLUSION: Sunitinib should be given via the 2/1 schedule in Indian patients.

Perioperative outcomes following robot-assisted partial nephrectomy for complex renal masses: A Vattikuti Collective Quality Initiative database study.

Introduction: Outcomes of robot-assisted partial nephrectomy (RAPN) depend on tumor complexity, surgeon experience and patient profile among other variables. We aimed to study the perioperative outcomes of RAPN for patients with complex renal masses using the Vattikuti Collective Quality Initiative (VCQI) database that allowed evaluation of multinational data. Methods: From the VCQI, we extracted data for all the patients who underwent RAPN with preoperative aspects and dimensions used for an anatomical (PADUA) score of ≥10. Multivariate logistic regression was conducted to ascertain predictors of trifecta (absence of complications, negative surgical margins, and warm ischemia times [WIT] <25 min or zero ischemia) outcomes. Results: Of 3,801 patients, 514 with PADUA scores ≥10 were included. The median operative time, WIT, and blood loss were 173 (range 45-546) min, 21 (range 0-55) min, and 150 (range 50-3500) ml, respectively. Intraoperative complications and blood transfusions were reported in 2.1% and 6%, respectively. In 8.8% of the patients, postoperative complications were noted, and surgical margins were positive in 10.3% of the patients. Trifecta could be achieved in 60.7% of patients. Clinical tumor size, duration of surgery, WIT, and complication rates were significantly higher in the group with a high (12 or 13) PADUA score while the trifecta was significantly lower in this group (48.4%). On multivariate analysis, surgical approach (retroperitoneal vs. transperitoneal) and high PADUA score (12/13) were identified as predictors of the trifecta outcomes. Conclusion: RAPN may be a reasonable surgical option for patients with complex renal masses with acceptable perioperative outcomes.