A Comprehensive Review of the Current State of Robot-assisted Laparoscopic Salvage Prostatectomy

ABSTRACT Background and Objective Salvage robot assisted radical prostatectomy (sRARP) is performed for patients with biochemical or biopsy proven, localized prostate cancer recurrences after radiation or ablative therapies. Traditionally, sRARP has been avoided by lower volume surgeons due to technical demand and high complication rates. Post-radiation sRARP outcomes studies exist but remain few in number. With increasing use of whole gland and focal ablative therapies, updates on sRARP in this setting are needed. The aim of this narrative review is to provide an overview of recently reviewed studies on the oncologic outcomes, functional outcomes, and complications after post-radiation and post-ablative sRARP. Tips and tricks are provided to guide surgeons who may perform sRARP. Materials and Methods We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010-2022 without limitation on study design. Only case reports, editorial comments, letters, and manuscripts in non-English languages were excluded. Key Content and Findings Salvage robotic radical prostatectomy is performed in cases of biochemical recurrence after radiation or ablative therapies. Oncologic outcomes after sRARP are worse compared to primary surgery (pRARP) though improvements have been made with the robotic approach when compared to open salvage prostatectomy. Higher pre-sRARP PSA levels and more advanced pathologic stage portend worse oncologic outcomes. Patients meeting low-risk, EAU-biochemical recurrence criteria have improved oncologic outcomes compared to those with high-risk BCR. While complication rates in sRARP are higher compared to pRARP, Retzius sparing approaches may reduce complication rates, particularly rectal injuries. In comparison to the traditional open approach, sRARP is associated with a lower rate of bladder neck contracture. In terms of functional outcomes, potency rates after sRARP are poor and continence rates are low, though Retzius sparing approaches demonstrate acceptable recovery of urinary continence by 1 year, post-operatively. Conclusions Advances in the robotic platform and improvement in robotic experience have resulted in acceptable complication rates after sRARP. However, oncologic and functional outcomes after sRARP in both the post-radiation and post-ablation settings are worse compared to pRARP. Thus, when engaging in shared decision making with patients regarding the initial management of localized prostate cancer, patients should be educated regarding oncologic and functional outcomes and complications in the case of biochemically recurrent prostate cancer that may require sRARP.

A Comprehensive Review of the Current State of Robot-assisted Laparoscopic Salvage Prostatectomy.

BACKGROUND AND OBJECTIVE: Salvage robot assisted radical prostatectomy (sRARP) is performed for patients with biochemical or biopsy proven, localized prostate cancer recurrences after radiation or ablative therapies. Traditionally, sRARP has been avoided by lower volume surgeons due to technical demand and high complication rates. Post-radiation sRARP outcomes studies exist but remain few in number. With increasing use of whole gland and focal ablative therapies, updates on sRARP in this setting are needed. The aim of this narrative review is to provide an overview of recently reviewed studies on the oncologic outcomes, functional outcomes, and complications after post-radiation and post-ablative sRARP. Tips and tricks are provided to guide surgeons who may perform sRARP. MATERIALS AND METHODS: We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010-2022 without limitation on study design. Only case reports, editorial comments, letters, and manuscripts in non-English languages were excluded. Key Content and Findings: Salvage robotic radical prostatectomy is performed in cases of biochemical recurrence after radiation or ablative therapies. Oncologic outcomes after sRARP are worse compared to primary surgery (pRARP) though improvements have been made with the robotic approach when compared to open salvage prostatectomy. Higher pre-sRARP PSA levels and more advanced pathologic stage portend worse oncologic outcomes. Patients meeting low-risk, EAU-biochemical recurrence criteria have improved oncologic outcomes compared to those with high-risk BCR. While complication rates in sRARP are higher compared to pRARP, Retzius sparing approaches may reduce complication rates, particularly rectal injuries. In comparison to the traditional open approach, sRARP is associated with a lower rate of bladder neck contracture. In terms of functional outcomes, potency rates after sRARP are poor and continence rates are low, though Retzius sparing approaches demonstrate acceptable recovery of urinary continence by 1 year, post-operatively. CONCLUSIONS: Advances in the robotic platform and improvement in robotic experience have resulted in acceptable complication rates after sRARP. However, oncologic and functional outcomes after sRARP in both the post-radiation and post-ablation settings are worse compared to pRARP. Thus, when engaging in shared decision making with patients regarding the initial management of localized prostate cancer, patients should be educated regarding oncologic and functional outcomes and complications in the case of biochemically recurrent prostate cancer that may require sRARP.

Surgeon-administered regional nerve blocks during radical cystectomy: a feasibility study.

OBJECTIVE: To describe the technique for surgeon-administered, ultrasound-guided transversus abdominis plane (SU-TAP) blocks performed during radical cystectomy as a component of multimodal, perioperative pain management. METHODS: Retrospective, case series of patients receiving SU-TAP blocks just prior to incision for RC. TAP blocks were performed by the surgeon with a standard technique using US guidance to instill an anesthetic solution. The primary outcome was opioid consumption at the intervals of 0-12, 12-24, 24-36, and 36-48 h postoperatively. Opioid consumption was reported as oral morphine milligram equivalents (MME). Secondary outcomes included time to perform SU-TAP blocks, and safety of block procedure. RESULTS: 34 patients were included. During the median length of stay of 4 days (interquartile range [IQR] 3-7), only 30/34 (88%) of patients required opioids within the first 12 h post-op, decreasing to 38% by 48 h post-op. The median consumption decreased in the first 48 h from 21 MMEs (IQR 9-38) to 10 MMEs (IQR 8-15) at the 0-12 and 36-48 h intervals, respectively. The median time to perform block procedure was 6 min (IQR 4-8 min) and there were no safety events related to the SU-TAP blocks. Limitations include no comparative arm for opioid consumption. CONCLUSION: Our data suggest that urologists may feasibly perform US-guided TAP blocks as a practical, efficient, and safe method of regional anesthesia. SU-TAP blocks should be considered in ERAS protocols for RC. Future comparative studies on opioid consumption compared to local infiltration and alternative block techniques are warranted.

Ileal Conduit versus Cutaneous Ureterostomy after Open Radical Cystectomy: Comparison of 90-Day Morbidity and Tube Dependence at Intermediate Term Follow-Up.

Background: This study aims to compare perioperative morbidity and drainage tube dependence following open radical cystectomy (ORC) with ileal conduit (IC) or cutaneous ureterostomy (CU) for bladder cancer. Methods: A single-center, retrospective cohort study of patients undergoing ORC with IC or CU urinary diversion between 2020 and 2023 was carried out. The 90-day perioperative morbidity, as per Clavien-Dindo (C.D.) complication rates (Minor C.D. I-II, Major C.D. III-V), and urinary drainage tube dependence (ureteral stent or nephrostomy tube) after tube-free trial were assessed. Results: The study included 56 patients (IC: 26, CU: 30) with a 14-month median follow-up. At 90 days after IC or CU, the frequencies of any, minor, and major C.D. complications were similar (any-69% vs. 77%; minor-61% vs. 73%; major-46% vs. 30%, respectively, p > 0.2). Tube-free trial was performed in 86% of patients with similar rates of tube replacement (19% IC vs. 32% CU, p = 0.34) and tube-free survival at 12 months was assessed (76% IC vs. 70% CU, p = 0.31). Conclusions: Compared to the ORC+IC, ORC+CU has similar rates of both 90-day perioperative complications and 12-month tube-free dependence. CU should be offered to select patients as an alternative to IC urinary diversion after RC.

Risk factors for infection and acute urinary retention following transperineal prostate biopsy.

PURPOSE: To calculate the frequency of infection and acute urinary retention (AUR) following transperineal (TP) prostate biopsy at a single high-volume academic institution and determine risk factors for developing these post-biopsy conditions. METHODS: Men undergoing TP prostate biopsy from 2012 to 2022 at our institution were retrospectively identified and chart reviewed. TP biopsies were performed with TR ultrasound (TRUS) guidance with anesthesia using a brachytherapy grid template. TRUS volumes were recorded during the procedure, and magnetic resonance imaging (MRI) volumes were calculated using the ellipsoid formula. When available, MRI volume was used for all analysis, and when absent, TRUS volume was used. AUR was defined as requiring urinary catheter placement within 72 h post-biopsy for inability to urinate. Univariable analysis was performed and variables with p < 0.1 and/or established clinical relevance were included in a backward binary logistic regression to produce an optimized model that fit the data without collinearity between variables. RESULTS: A total of 767 TP biopsies were completed in the study window. The frequency of infection was 1.83% (N = 14/767). The total frequency of AUR was 5.48% (N = 42/767). On multivariable regression, patients who went into AUR were five times as likely to develop infection (p = 0.020). Patients with infection post-TP biopsy were four times as likely to develop AUR (p = 0.047) and with prostates > 61.21 cc were three times as likely (p = 0.019). CONCLUSION: According to our model, AUR is the greatest risk factor for infection post-TP biopsy. With regard to AUR risks, infection post-biopsy and prostate size > 61.21 cc are the greatest risk factors.

Urothelial Carcinoma Recurrence With an Ileal Conduit: Multimodal Management With Extirpative Surgery, Chemotherapy, and Immunotherapy.

Ileal conduit (IC) is the most performed urinary diversion after radical cystectomy (RC) for urothelial carcinoma (UC) of the bladder. While UC recurrence after RC is well-described, recurrence of UC within a urinary diversion is much less prevalent, and thus, management of these lesions is not well understood. Here, we report the case of a 59-year-old male with a history of invasive UC with glandular differentiation of the urinary bladder who had carcinoma in situ recurrence after induction, intravesical Bacille Calmette-Guerin therapy. He underwent robot-assisted laparoscopic radical cystoprostatectomy (RALC) with bilateral pelvic lymph node dissection and intracorporal ileal conduit (IC) urinary diversion. Two years later, he presented to the emergency department with hematuria. Computed tomography demonstrated a mass within the IC. He subsequently underwent IC resection and ligation of bilateral ureters and had permanent nephrostomy tubes placed, with the final pathology confirming high-grade UC. Positron emission tomography revealed hypermetabolic soft tissue implants within the greater omentum and retroperitoneum for which he underwent fine-needle aspiration, demonstrating recurrence of poorly differentiated UC. Ultimately, the patient started treatment with systemic gemcitabine and carboplatin and completed 4 cycles before transitioning to maintenance avelumab therapy. No disease progression was noted at 16 months post-treatment. Herein, we present a review of the literature and our management of the present patient.

Laparoscopic and robotic urology surgery during global pandemic COVID-19

ABSTRACT Known laparoscopic and robotic assisted approaches and techniques for the surgical management of urological malignant and benign diseases are commonly used around the World. During the global pandemic COVID-19, urology surgeons had to reorganize their daily surgical practice. A concern with the use of minimally invasive techniques arose due to a proposed risk of viral transmission of the coronavirus disease with the creation of pneumoperitoneum. Due to this, we reviewed the literature to evaluate the use of laparoscopy and robotics during the pandemic COVID-19. A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID-19 virus was performed up to April 30, 2020. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. Few studies have been performed on viral transmission during surgery. No study has been made regarding this area during minimally invasive urology cases. To date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open, laparoscopic or robotic. There is no society consensus on restricting laparoscopic or robotic surgery. However, there is expert consensus on modification of standard practices to minimize any risk of transmission. During the pandemic COVID-19 we recommend the use of specific personal protective equipment for the surgeon, anesthesiologist and nursing staff in the operating room. Modifications of standard practices during minimally invasive surgery such as using lowest intra-abdominal pressures possible, controlled smoke evacuation systems, and minimizing energy device usage are recommended.

Laparoscopic and Robotic Urology Surgery during Global Pandemic COVID19.

Known laparoscopic and robotic assisted approaches and techniques for the surgical management of urological malignant and benign diseases are commonly used around the World. During the global pandemic COVID19, urology surgeons had to reorganize their daily surgical practice. A concern with the use of minimally invasive techniques arose due to a proposed risk of viral transmission of the coronavirus disease with the creation of pneumoperitoneum. Due to this, we reviewed the literature to evaluate the use of laparoscopy and robotics during the pandemic COVID19. A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID19 virus was performed up to April 30, 2020. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. Few studies have been performed on viral transmission during surgery. No study has been made regarding this area during minimally invasive urology cases. To date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open, laparoscopic or robotic. There is no society consensus on restricting laparoscopic or robotic surgery. However, there is expert consensus on modification of standard practices to minimize any risk of transmission. During the pandemic COVID19 we recommend the use of specific personal protective equipment for the surgeon, anesthesiologist and nursing staff in the operating room. Modifications of standard practices during minimally invasive surgery such as using lowest intra-abdominal pressures possible, controlled smoke evacuation systems, and minimizing energy device usage are recommended.

Safety and Feasibility of Laparoscopic Nephrectomy for Big Tumors (≥ 10 cm): A Retrospective Multicentric Study.

OBJECTIVE: Evaluate the feasibility of laparoscopic nephrectomy for big tumors. MATERIAL AND METHODS: Data from 116 patients were retrospectively collected from 16 tertiary centres. Clinical and operative parameters, tumor characteristics, pre- and postoperative parameters, and renal function before and after surgery were analyzed. RESULTS: Mean age and body mass index were 61 years and 27.8 kg/m(2), respectively. Males represented 63.8% of patients, and 54.4% presented symptoms at diagnosis. Median tumor size was 11 cm, and 75% of the cases were performed by expert surgeons. Median operative time and blood loss were 180 minutes and 200 mL respectively. Conversion to open surgery was necessary in 20.7% of cases. Intraoperative complications related to massive hemorrhage occurred in 16.4% of patients, resulting in open conversion in 62.5%. Major postoperative complications occurred in only 10 patients (8.6%). In univariate analysis, intraoperative complications, age, and blood loss were predictive factors of conversion to open surgery. Positive surgical margins occurred in 6 patients (5.2%). None of them presented a local recurrence. Predictive factors of recurrence or progression were lymph node invasion, metastases, and Furhman grade. CONCLUSION: Laparoscopic nephrectomy for tumors > 10 cm can be performed safely. Complication rate and positive surgical margins are similar to open surgery. In experienced hands, the benefit of a mini invasive surgery remains evident.

Primary Ewing sarcoma of the kidney: a symptomatic presentation and review of the literature.

The objective of this review is to discuss the unique nature of primary renal Ewing sarcoma, including incidence, presentation and management. We also report on a common pattern of presentation, consisting of acute flank pain mimicking a renal stone colic, with or without hydronephrosis, and a renal mass discovered during imaging studies of renal Ewing sarcoma. We present our case of renal Ewing sarcoma along with imaging and pathological analysis. We also performed a retrospective review of all cases of renal Ewing sarcoma using PubMed. A total of 48 cases of renal EWS sarcoma have been reported and analyzed in this review. A mean age of 30.4 years was found along with a 61% male predominance. The mean survival was 26.14 months with a lower median survival in patients with advanced metastatic disease. Primary Ewing sarcoma of the kidney is rare. The diagnosis of primary renal EWS can be difficult and is based on a combination of electron microscopy, immunohistochemistry, chromosomal analysis, fluorescence in situ hybridization (FISH) and light microscopy.

Surgical management of a locally advanced symptomatic recurrence of penile sarcoma secondary to prostate brachytherapy.

UNLABELLED: The surgical management of patients with symptomatic metastatic or locally advanced recurrences involving the penis remains poorly characterized. The aim of the present abstract and video is to detail our experience in the surgical management of a specific patient with a locally advanced symptomatic recurrence of penile sarcoma secondary to prostate cancer treated with primary brachytherapy. MATERIALS AND METHODS: A 70 year old male patient initially treated for localized prostate cancer with interstitial brachytherapy at an outside facility developed an unfortunate secondary malignancy consisting of a locally advanced penile sarcoma involving as well the prostate and base of the bladder. Despite our best efforts to control his pain, he developed a very symptomatic local recurrence with a secondary penile abscess and purulent periurethral drainage. At this time, it was felt a surgical resection consisting of a total penectomy, urethrectomy, cystoprostatectomy, and ileal conduit urinary diversion would be the best option for local cancer control in this particular patient. RESULTS: The patient underwent the surgical resection without any complications as illustrated in this surgical video, with a jejunal intestinal mass identified at the time of surgery which was resected with a primary bowel anastomosis performed. The patient was discharged from hospital uneventfully with his symptomatic local recurrence being successfully managed and the patient no longer requiring oral narcotics for pain control. The pathological report confirmed a locally advanced sarcoma involving the penile, prostate, and bladder which was resected with negative surgical margins and the jejunal mass was confirmed to represent a small bowel sarcoma metastatic site. CONCLUSION: As highlighted in the present video, the treatment of a symptomatic sarcoma local recurrence contiguously involving the penis can be successfully managed provided the patient is informed of the potential morbidity and psychosocial implications imparted by performing a total penectomy and adjacent organ resection.

Surgical Management of a Locally Advanced Symptomatic Recurrence of Penile Sarcoma Secondary to Prostate Brachytherapy

Background The surgical management of patients with symptomatic metastatic or locally advanced recurrences involving the penis remains poorly characterized. The aim of the present abstract and video is to detail our experience in the surgical management of a specific patient with a locally advanced symptomatic recurrence of penile sarcoma secondary to prostate cancer treated with primary brachytherapy. Materials and Methods A 70 year old male patient initially treated for localized prostate cancer with interstitial brachytherapy at an outside facility developed an unfortunate secondary malignancy consisting of a locally advanced penile sarcoma involving as well the prostate and base of the bladder. Despite our best efforts to control his pain, he developed a very symptomatic local recurrence with a secondary penile abscess and purulent periurethral drainage. At this time, it was felt a surgical resection consisting of a total penectomy, urethrectomy, cystoprostatectomy, and ileal conduit urinary diversion would be the best option for local cancer control in this particular patient. Results The patient underwent the surgical resection without any complications as illustrated in this surgical video, with a jejunal intestinal mass identified at the time of surgery which was resected with a primary bowel anastomosis performed. The patient was discharged from hospital uneventfully with his symptomatic local recurrence being successfully managed and the patient no longer requiring oral narcotics for pain control. The pathological report confirmed a locally advanced sarcoma involving the penile, prostate, and bladder which was resected with negative surgical margins and the jejunal mass was confirmed to represent a small bowel sarcoma metastatic site. Conclusion As highlighted in the present video, the treatment of a symptomatic sarcoma local recurrence contiguously involving the penis can be successfully managed provided the patient ...

Ventral phalloplasty.

PURPOSE: To present the surgical technique of ventral phalloplasty as an adjunct procedure to the classic prosthetic surgery. MATERIALS AND METHODS: In this video we demonstrate how to perform a ventral phalloplasty in a patient that has undergone a penile prosthesis implantation. Our technique consists of: delineation of the penile scrotal web, excision of this redundant skin, and re-approximation of the wound to mimic the natural median raphe. RESULTS: The ventral phalloplasty improves the perception of phallic length, as well as patients' satisfaction after prosthetic surgery. CONCLUSION: Penile length perception is the main concern of patients that have undergone penile prosthesis implantation. In this video we demonstrate that the ventral phalloplasty can improve perception of phallic length, and can be an important adjunct to the classic prosthetic surgery.

Is the R.E.N.A.L. nephrometry scoring system predictive of the functional efficacy of nephron sparing surgery in the solitary kidney?

PURPOSE: We evaluated the ability of renal tumor complexity, as assessed by the R.E.N.A.L. (radius, exophytic, nearness to collecting system, anterior/posterior and location) nephrometry scoring system, to predict the functional efficacy of nephron sparing surgery. MATERIALS AND METHODS: We evaluated 42 patients who presented with an anatomically (32) or a functionally (10) solitary kidney and underwent partial nephrectomy. Each renal unit was assigned a R.E.N.A.L. nephrometry score using preoperative imaging. The CKD-EPI equation was applied to calculate the estimated glomerular filtration rate. The difference between the estimated glomerular filtration rate at baseline and at postoperative time points served as a measurement of the renal functional loss attributable to partial nephrectomy. RESULTS: In the 42 patients who underwent partial nephrectomy the mean preoperative estimated glomerular filtration rate was 61.5 ml/minute/1.73 m(2). The median total nephrometry score was 8 (range 4 to 10). In the immediate postoperative period the cohort mean estimated glomerular filtration rate of 48.6 ml/minute/1.73 m(2) was significantly less than the preoperative value (p <0.0001). At 6-month followup the mean estimated glomerular filtration rate had recovered at 54.1 ml/minute/1.73 m(2) but it remained significantly less than the preoperative value (p = 0.0002). We noted no relationship between the postoperative decrease in the estimated glomerular filtration rate and the assigned total nephrometry score or in any individual component of the R.E.N.A.L. scoring system related to the targeted lesion. CONCLUSIONS: Neither the individual components of the R.E.N.A.L. nephrometry scoring system nor the total nephrometry score predicted the realized functional loss, as assessed by the estimated glomerular filtration rate in patients with a solitary kidney treated with nephron sparing surgery. However, nephron sparing surgery was quite efficacious for preserving renal function since only a durable 11.6% decrease was noted in the estimated glomerular filtration rate.

Stentless pediatric robotic pyeloplasty.

OBJECTIVES: Open dismembered pyeloplasty remains the standard of care for the correction of ureteropelvic junction obstruction in children. We describe our experience with a tubeless, stentless pediatric robotic pyeloplasty technique. METHODS: Between October 2008 and September 2009, 12 consecutive children underwent robotic dismembered pyeloplasty. Ureteral stents or nephrostomy tubes were not used. Operative time, hospital stay, days of Jackson-Pratt drainage, and complications were analyzed. Postoperative renal ultrasonography was obtained at 4-6 weeks after surgery. RESULTS: The mean patient age was 9.1 years (3.5-16). The mean operative and console times were 178 (122-250) and 129 (96-193) minutes, respectively. The Jackson-Pratt drain was removed after a mean of 1.8 days (1-4). The mean hospital stay was 2.4 days (1-4.5). There were no complications. Mean follow up was 16 months (12-24 months). All patients had complete resolution of symptoms. Hydronephrosis either completely resolved or significantly decreased in all cases. In cases without complete resolution of hydronephrosis, 99m Tc-MAG-3 diuretic renography showed preservation of renal function without obstruction. CONCLUSIONS: Robot-assisted laparoscopic pyeloplasty can be safely performed without internal indwelling stent drainage. In children, this avoids the need for additional anesthesia and stent-related morbidity.