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OBJECTIVE: To perform a systematic review and meta-analysis of trials comparing trimodal therapy (TMT) and radical cystectomy (RC), evaluating differences in terms of oncological outcomes, quality of life, and costs. MATERIALS AND METHODS: In July 2023, a literature search of multiple databases was conducted to identify studies analysing patients with cT2-4 N any M0 muscle-invasive bladder cancer (MIBC; Patients) receiving TMT (Intervention) compared to RC (Comparison), to evaluate survival outcomes, recurrence rates, costs, and quality of life (Outcomes). The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS) and metastasis-free survival (MFS). Hazard ratios (HRs) were used to analyse survival outcomes according to different treatment modalities and odds ratios were used to evaluate the likelihood of receiving each type of treatment according to T stage. RESULTS: No significant difference in terms of OS was observed between RC and TMT (HR 1.07, 95% confidence interval [CI] 0.81-1.4; P = 0.6), even when analysing radiation therapy regimens ≥60 Gy (HR 1.02, 95% CI 0.69-1.52; P = 0.9). No significant difference was observed in CSS (HR 1.12, 95% CI 0.79-1.57, P = 0.5) or MFS (HR 0.88, 95% CI 0.66-1.16; P = 0.3). The mean cost of TMT was significantly higher than that of RC ($289 142 vs $148 757; P < 0.001), with greater effectiveness in terms of cost per quality-adjusted life-year. TMT ensured significantly higher general quality-of-life scores. CONCLUSION: Trimodal therapy appeared to yield comparable oncological outcomes to RC concerning OS, CSS and MFS, while providing superior patient quality of life and cost effectiveness.
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PURPOSE: To evaluate the incidence of postoperative complications after cytoreductive nephrectomy (CN) following first-line treatment for metastatic renal cell carcinoma (mRCC), and to compare it with postoperative complications of upfront CN. METHODS: For this population-based retrospective study, the PearlDiver Mariner database (PearlDiver Technologies, Colorado Springs, CO), a database of insurance billing records was analyzed. Using relevant ICD-9/10 and CPT codes, patients diagnosed with mRCC between 2011 and 2021, who received first-line systemic molecular therapy (SMT), either tyrosine kinase inhibitors (TKI) or immune-checkpoint inhibitors (ICI), were identified. The selected population was stratified into two cohorts according to the timing of CN (deferred: after SMT vs. upfront: before SMT). Propensity-score matching (PSM) was performed as per baseline patients' characteristics to control for potential confounders between the two cohorts. The primary outcome was to compare 30-day postoperative complications rate between patients undergoing upfront vs. deferred CN. RESULTS: After PSM, 162 patients who received upfront CN were compared with 162 patients who underwent deferred CN. The overall rate of 30-day postoperative complications was statistically significantly higher in patients undergoing deferred CN (33.9%), compared to patients treated with upfront CN (21%, p < 0.01). In addition, the rate of both medical (26.5% vs. 14.2%, p < 0.01) and surgical (14.8 vs. 7.4%, p = 0.03) complication rate was statistically significantly higher in deferred vs. upfront CN. Multivariable logistic regression analysis revealed that none of the treatment regimens significantly predicted the occurrence of postoperative complications. CONCLUSION: Patients undergoing deferred CN experience a higher rates of overall, medical, and surgical 30-day postoperative complications compared to those receiving upfront surgery. Findings from this study should be interpreted within the limitations of this type of analysis.
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Carcinoma de Células Renais , Procedimentos Cirúrgicos de Citorredução , Imunoterapia , Neoplasias Renais , Nefrectomia , Complicações Pós-Operatórias , Pontuação de Propensão , Humanos , Neoplasias Renais/cirurgia , Neoplasias Renais/tratamento farmacológico , Nefrectomia/métodos , Masculino , Feminino , Carcinoma de Células Renais/cirurgia , Carcinoma de Células Renais/tratamento farmacológico , Carcinoma de Células Renais/terapia , Pessoa de Meia-Idade , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Idoso , Terapia de Alvo Molecular , IncidênciaRESUMO
PURPOSE: Single-Port Robot-Assisted Partial Nephrectomy (SP-RAPN) can be performed by transperitoneal and retroperitoneal approaches. However, there is a lack of surgical outcomes for novel Retroperitoneal Low Anterior Access (LAA) in SP-RAPN. The study compared outcomes of the standard approach (SA), considering transperitoneal (TP) and posterior retroperitoneal (RP) access vs LAA in SP-RAPN series. METHODS: 102 consecutive patients underwent SP-RAPN between 2019 and 2023 at a tertiary referral robotic center were identified. Baseline characteristics, peri- and post-operative outcomes were collected. Patients were stratified according to surgical approach into standard (RP or TP) vs LAA and, subsequently, RP vs LAA. Multivariable logistic regression analysis was used to test the probability of the same-day discharge adjusting for comorbidity indexes. RESULTS: Overall, 102 consecutive patients were included in this study (68 SA - 26 TP and 42 posterior RP vs 34 LAA). Median age was 60 (IQR 51.5-66) years and median BMI was 31 (IQR 26.3-37.6). No baseline differences were observed. LAA exhibited significantly shorter length of stay (LOS) (median 10 [IQR 8-12] vs 24 [IQR 12-30.2.] hours, p < .0001), reduced post-operative pain (p < .0001) and decreased narcotic use on 0-1 PO Day (p < .001) compared to SA and RP only. Multivariate analysis, adjusting for comorbidities, identified LAA as a strong predictor for Same-Day Discharge. CONCLUSION: LAA is an effective approach as well as RP and TP, regardless of the renal mass location, whether it is anterior or posterior, upper/mid or lower pole, yielding favorable outcomes in LOS, post-operative pain and decreased narcotics use compared to SA in SP-RAPN.
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Nefrectomia , Procedimentos Cirúrgicos Robóticos , Humanos , Nefrectomia/métodos , Pessoa de Meia-Idade , Masculino , Feminino , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Espaço Retroperitoneal , Resultado do Tratamento , Estudos Retrospectivos , Peritônio/cirurgia , Neoplasias Renais/cirurgiaRESUMO
INTRODUCTION: The introduction of Single-Port (SP) platform opened the field to new surgical options, allowing to perform major urological robot-assisted procedures extraperitoneally and with a supine patient positioning (1-3). Nevertheless, a comprehensive description of different supine access options is still lacking (4-6). In this light, we provided a step-by-step guide of SP extraperitoneal supine access options also exploring preliminary surgical outcomes. MATERIALS AND METHODS: Transvesical access was performed by a transversal incision 3cm above the pubic bone, after the anterior abdominal sheet incision, the bladder was insufflated with a flexible cystoscope and the detrusor muscle was incised at the level of the bladder dome. Similarly, the extraperitoneal access was carried out with a 4cm incision above the pubic bone, once visualized the preperitoneal space the prevesical fat was gently spread. The Low Anterior Access was performed with a 3cm incision at the McBurney point, the abdominal muscles were then spread. A gentle dissection was used laterally to develop the retroperitoneal space. RESULTS: Overall, sixteen different procedures were performed with supine extraperitoneal access on 623 consecutive patients. No intraoperative conversions occurred. The median access time was 16 (IQR 12-21), 11 (IQR 7-14) and 14 (IQR 10-18) minutes in case of transvesical, extraperitoneal and low anterior access, respectively. Notably, 81.5 % of patients were discharged on the same day with a postoperative opioid free rate of 73%. CONCLUSION: The Atlas provides a comprehensive step-by-step guide to successfully perform all major urological SP procedures extraperitoneally and with supine patient positioning.
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INTRODUCTION: Vesicovaginal fistula (VVF) is the most common urogenital fistula due to iatrogenic cause, primarily associated with gynecologic surgery (1). Although both conservative and surgical management may be considered, the optimal treatment is still uncertain and several studies were published using different techniques (open, laparoscopic or robotic) and approaches (extravesical, transvesical or transvaginal) (2-5). In this context, we aim to report our initial experience repairing VVF with Single-Port (SP) Transvesical (TV) access. MATERIALS AND METHODS: Four patients with a diagnosis of VVF underwent SP-TV VVF repair between May 2022 and December 2023. Diagnosis was confirmed by cystoscopy, cystogram and in two cases by CT Urogram. Under general anesthesia, before robotic time, patients were placed in lithotomy position and a preliminary cystoscopy was performed. Fistula was noted and a 5fr stent was placed through the fistulous tract. Two ureteral stents were placed. Then, with patient supine, a transverse suprapubic 3cm incision and 2cm cystotomy were made for SP access. First step was to mark and remove fistula tract to the vagina. The edges of the vagina and bladder were dissected in order to have a closure free of tension and to create three different layers to close: vagina, muscularis layer of the bladder and mucosal layer of the bladder. A bladder catheter was placed, and the two ureteral stents were removed at the end of procedure. RESULTS: Mean age was 53 years old and three out of 4 patients developed VVF after gynecologic surgery. Two patients underwent VVF repair 6 and 8 months after total hysterectomy. One patient developed VVF after total hysterectomy and oophorectomy followed by radiation therapy. Last patient developed VVF after previous urological procedure. Fistula diameter was between 11 and 15mm. Operative time was 211 min, including preliminary cystoscopy, stents placement and SP-access. All patients were discharged on the same day with a bladder catheter, successfully removed between post-operative day 14-18 after negative cystogram. Only in one case a ureteral stent was left because the fistula was closed to the ureteral orifice and we reported one case of UTI twelve days after surgery, treated with outpatient antibiotics. Mean follow-up was 8 months, patients were scheduled for regular follow-up visits and no recurrence was reported. All patients have at least 3 months of post-operative follow-up. CONCLUSIONS: Our experience suggests that SP Transvesical VVF repair may be considered as a safe and feasible minimally invasive treatment for small/medium fistulae (10-15mm).
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Fístula Vesicovaginal , Humanos , Feminino , Fístula Vesicovaginal/cirurgia , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto , Procedimentos Cirúrgicos Robóticos/métodos , Cistoscopia/métodos , Reprodutibilidade dos Testes , Duração da CirurgiaRESUMO
OBJECTIVE: To evaluate the perioperative complications of single-port robot-assisted radical prostatectomy (SP-RARP). PATIENTS AND METHODS: A retrospective review was performed on the prospectively maintained, Institutional Review Board-approved, multi-institutional Single-Port Advanced Research Consortium (SPARC) database. A total of 1103 patients were identified who underwent three different approaches of SP-RARP between 2019 and 2022 using the purpose-built SP robotic platform. In addition to baseline clinical, perioperative outcomes, this study comprehensively analysed for any evidence of intraoperative complication, as well as postoperative complication and readmission within 90 days of the respective surgery. RESULTS: Of the 244, 712, and 147 patients who underwent transperitoneal, extraperitoneal, and transvesical SP-RARP, respectively, intraoperative complications were noted in five patients (0.4%), all of which occurred during the transperitoneal approach. Two patients had bowel serosal tears, two had posterior button-holing of the bladder necessitating repair, and one patient had an obturator nerve injury. Postoperative complications were noted in 143 patients (13%) with major complications (Clavien-Dindo Grade ≥III) only identified in 3.7% of the total cohort. The most common complications were lymphocele (3.9%), acute urinary retention (2%), and urinary tract infection (1.9%). The 90-day re-admission rate was 3.9%. CONCLUSION: The SP-RARP is a safe and effective procedure with low complication and readmission rates regardless of the approach. These results are comparable to current multi-port RARP literature.
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INTRODUCTION: Gender dysphoria affects over 1 million American adults. Vaginoplasty is a critical step in gender affirmation, and many patients have insufficient genital skin for full-depth penile inversion vaginoplasty (PIV). We reviewed the literature for technical considerations addressing this and present our data supporting the use of peritoneal flaps (Davydov technique). MATERIALS AND METHODS: A comprehensive review of modern literature was conducted. Second, we present a retrospective case review of our experience with PIV, including data from procedures utilizing peritoneal flaps. RESULTS: We identified 20 original articles, including retrospective and prospective case and cohort studies. Approaches included the application of local soft tissue grafts and flaps, peritoneal flaps, and intestinal segments. Between June 2018 and February 2021, 47 patients at our institution, underwent PIV for the treatment of gender dysphoria. Nineteen of those patients underwent robotic-assisted peritoneal flap procedure in addition to PIV. In this cohort, the mean follow-up was 200.6 ± 124.8 days. Mean neovaginal depth was 13.1 ± 3.0 cm intra-operatively and 11.0 cm at the last follow-up. Twenty-six percent of complications were Clavien Grade 1 or 2; others included wound dehiscence (30.4%), perianal and urethral fistula (13.0%), and neovaginal stenosis (8.7%). The majority of patients reported satisfactory results in terms of sexual function with intact tactile and erogenous sensation. Almost half were able to have penetrative vaginal intercourse at the last follow-up. We did not aim to perform statistical calculations to compare the outcomes of PIV with and without robotic-assisted peritoneal flap augmentation, as the groups were not constructed in that manner. However, it is evident that anatomical and functional results as well as the distribution of postoperative complications seem similar. CONCLUSION: Vaginoplasty is indicated in a growing population of patients with a wide range of medical histories and anatomic variations. Genitourinary reconstructive surgeons must have several methods to achieve full-depth vaginoplasty in cases of inadequate genital skin. Peritoneal flaps serve as a versatile, safe, and functionally advantageous solution.
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Cirurgia de Readequação Sexual , Adulto , Feminino , Humanos , Cirurgia de Readequação Sexual/efeitos adversos , Cirurgia de Readequação Sexual/métodos , Estudos Retrospectivos , Retalhos Cirúrgicos/cirurgia , Períneo/cirurgia , Complicações Pós-Operatórias/etiologia , Vagina/cirurgiaRESUMO
PURPOSE OF REVIEW: To evaluate recent literature regarding the role of robotic technology in the treatment of nephrolithiasis with particular attention to complex technical procedures. RECENT FINDINGS: Robotic platforms including single-port robotics have been widely adopted in urological practice for the treatment of both malignant and benign conditions and has led to an expansion of the utilization of robot-assisted surgery to tackle challenging clinical scenarios such as bladder neck reconstruction, upper urinary tract reconstruction, and more recently complex stone disease. Presently, the American Urological Association guidelines on the surgical management of stones advise against using robotic, open, or laparoscopic techniques as a first-line approach for most patients with stone disease with the exception for patients with anatomical abnormalities, large or complex stones, or patients requiring a concomitant reconstructive operation. Clinicians have demonstrated the safety and feasibility of surgical robotics in the treatment of stone disease for a variety of operations including robotic pyeloplasty, pyelolithotomy, ureterolithotomy, and surgical interventions in urinary diversions as well as novel technologies for robotic ureteroscopy and percutaneous access. Numerous clinicians have demonstrated the safety and feasibility of using robot-assisted surgery to treat nephrolithiasis, mainly in complex renal anatomy. Further research is necessary to identify the best candidates for utilization of robotics in complex stone disease, and further technological developments will continue to further advance the use of these platforms in the treatment of nephrolithiasis.
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Cálculos Renais , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Cálculos Renais/cirurgia , Rim , Laparoscopia/métodos , Resultado do TratamentoRESUMO
PURPOSE: Single-port (SP) robotic-assisted simple prostatectomy (RASP) through the transvesical approach is a novel surgical option in the management of large prostatic glands. We present the first multi-institutional study to further assess the perioperative and postoperative outcomes of SP RASP. MATERIALS AND METHODS: From February 2019 to November 2021, 91 consecutive patients of 3 separate institutions underwent transvesical RASP using the da Vinci® SP robotic surgical system. Surgeries were performed by 3 experienced surgeons. Through a suprapubic incision and transvesical access, the SP robot is docked directly into the bladder, and the prostatic enucleation is performed. Prospective data collection, including baseline characteristics, perioperative and postoperative outcomes, was performed. The mean followup period was 4.6 months. RESULTS: The mean (SD) prostate volume was 156 (62) ml. The mean (SD) total operative time was 159 (45) minutes, and the median (IQR) estimated blood loss was 100 (50, 200) cc. The median (IQR) postoperative hospital stay was 21.0 (6.5, 26.0) hours; however, 42% of all patients were discharged the same day. The median (IQR) Foley catheter duration was 5 (5, 7) days. Only 3 patients (3%) developed Clavien grade 2 postoperative complications. At 9-month followup, the median (IQR) International Prostate Symptom Score and quality of life score were 4 (2, 5) and 0 (0, 1), respectively, with a mean (SD) maximum flow rate and post-void residual of 21 (17) ml/second and 40 (55) ml, respectively. CONCLUSIONS: In a multi-institutional setting, the SP RASP promotes a pain-free procedure, same-day discharge, short Foley catheter duration, low complication rate and quick recovery.
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Hiperplasia Prostática , Neoplasias da Próstata , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Masculino , Prostatectomia/métodos , Hiperplasia Prostática/complicações , Hiperplasia Prostática/cirurgia , Neoplasias da Próstata/cirurgia , Qualidade de Vida , Procedimentos Cirúrgicos Robóticos/métodos , Robótica/métodos , Resultado do TratamentoRESUMO
Herein, we analyze answers achieved, open questions, and future perspectives regarding the analysis of the pathogenetic variants (PV) of DNA damage response (and repair) (DDR) genes in prostate cancer (PC) patients. The incidence of PVs in homologous recombination repair (HRR) genes among men with metastatic PC varied between 11% and 33%, which was significantly higher than that in non-metastatic PC, and BRCA2 mutations were more frequent when compared to other DDR genes. The determination of the somatic or germline PVs of BRCA2 was able to define a tailored therapy using PARP inhibitors in metastatic castration-resistant prostate cancer (mCRPC) progression after first-line therapy, with significant improvements in the radiologic progression-free survival (rPFS) and overall survival (OS) rates. We propose testing all metastatic PC patients for somatic and germline HRR mutations. Somatic determination on the primary site or on historic paraffin preparations with a temporal distance of no longer than 5 years should be preferred over metastatic site biopsies. The prognostic use of DDR PVs will also be used in selected high-risk cases with non-metastatic stages to better arrange controls and therapeutic primary options. We anticipate that the use of poly-ADP-ribose polymerase (PARP) inhibitors in hormone-sensitive prostate cancer (HSPC) and in combination with androgen receptor signaling inhibitors (ARSI) will be new strategies.
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Neoplasias de Próstata Resistentes à Castração , Neoplasias da Próstata , Masculino , Humanos , Neoplasias da Próstata/tratamento farmacológico , Neoplasias da Próstata/genética , Neoplasias da Próstata/patologia , Mutação em Linhagem Germinativa , Inibidores de Poli(ADP-Ribose) Polimerases/farmacologia , Inibidores de Poli(ADP-Ribose) Polimerases/uso terapêutico , Intervalo Livre de Progressão , Proteína BRCA1/genética , Neoplasias de Próstata Resistentes à Castração/tratamento farmacológico , Neoplasias de Próstata Resistentes à Castração/genética , Neoplasias de Próstata Resistentes à Castração/patologiaRESUMO
BACKGROUND: The da Vinci SP robot consists of an innovative single port trocar that houses a flexible camera and three biarticulated arms, which minimizes the number of incisions to assess the surgical site, allowing a less invasive procedure. However, due to its recent release in the market, the current literature reporting SP-RARP is still restricted to a few centers. In this scenario, after performing a literature search with all available techniques of SP-RARP, our objective is to report a multicentric opinion of referral centers on different techniques to approach SP-RARP. RESULTS: The SP literature is provided by only a few centers due to the limited number of this new console in the market. Five different approaches are available: transperitoneal, extraperitoneal, Retzius-Sparing, transperineal and transvesical. None of the current studies describe long-term functional or oncological outcomes. However, all approaches had satisfactory operative performance with minimum complication rates. CONCLUSIONS: Several techniques of SP-RARP have been reported in the literature. We performed a multicentric collaboration describing and illustrating the most challenging steps of this surgery. We believe that the details provided in this article are useful teaching material for new centers willing to adopt the SP technology.
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Procedimentos Cirúrgicos Robóticos , Prova Pericial , Humanos , Masculino , Próstata/cirurgia , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodosRESUMO
INTRODUCTION: Several techniques of robotic-assisted radical prostatectomy (RARP) using the da Vinci SP (SP) have been described since its clearance by the FDA (Food and Drug Administration) in 2018 (1, 2). Even with the expanding literature about this robot, the SP technology has been restricted to a few centers in the US and Asia due to the recent release of this robot in the marked.3 In this scenario, we provided, in this video compilation, a consensus of SP referral centers describing the current approaches and techniques of da Vinci SP Radical prostatectomy (SP-RARP). SURGICAL TECHNIQUE: We have illustrated five different techniques, including transperitoneal, extraperitoneal, Retzius-sparing, transvesical, and transperineal (4-6). Each surgery demonstrated crucial steps from the trocar placement until anastomosis. All approaches follow anatomic concepts and landmarks to minimize positive surgical margins, optimize oncological outcomes and promote optimal functional recovery. The trocar placement and the use of an assistant port were selected according to the operative technique of each institution. None of these surgeries had intra- or postoperative complications, and the pain management until discharge was controlled without using narcotics. All patients were discharged in less than 16 hours of surgery. CONCLUSION: Robotic-assisted radical prostatectomy performed with the da Vinci SP is feasible and safe with optimal perioperative outcomes. Five different approaches were described in this video compilation, and we believe that the technical details provided by this multicentric collaboration are crucial for centers willing to initiate the SP approach to radical prostatectomy.
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Procedimentos Cirúrgicos Robóticos , Humanos , Masculino , Margens de Excisão , Próstata/cirurgia , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Glândulas SeminaisRESUMO
OBJECTIVE: To describe the trend in surgical volume in urology in Italy during the coronavirus disease 2019 (COVID-19) outbreak, as a result of the abrupt reorganisation of the Italian national health system to augment care provision to symptomatic patients with COVID-19. METHODS: A total of 33 urological units with physicians affiliated to the AGILE consortium (Italian Group for Advanced Laparo-Endoscopic Surgery; www.agilegroup.it) were surveyed. Urologists were asked to report the amount of surgical elective procedures week-by-week, from the beginning of the emergency to the following month. RESULTS: The 33 hospitals involved in the study account overall for 22 945 beds and are distributed in 13/20 Italian regions. Before the outbreak, the involved urology units performed overall 1213 procedures/week, half of which were oncological. A month later, the number of surgeries had declined by 78%. Lombardy, the first region with positive COVID-19 cases, experienced a 94% reduction. The decrease in oncological and non-oncological surgical activity was 35.9% and 89%, respectively. The trend of the decline showed a delay of roughly 2 weeks for the other regions. CONCLUSION: Italy, a country with a high fatality rate from COVID-19, experienced a sudden decline in surgical activity. This decline was inversely related to the increase in COVID-19 care, with potential harm particularly in the oncological field. The Italian experience may be helpful for future surgical pre-planning in other countries not so drastically affected by the disease to date.
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COVID-19/epidemiologia , Pandemias , SARS-CoV-2 , Doenças Urológicas/cirurgia , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos , Comorbidade , Procedimentos Cirúrgicos Eletivos , Humanos , Itália/epidemiologia , Inquéritos e Questionários , Doenças Urológicas/epidemiologiaRESUMO
PURPOSE: Despite its success in the assessment of prostate cancer (PCa), in vivo multiparametric MRI has limitations such as interobserver variability and low specificity. Several MRI methods, among them MR elastography, are currently being discussed as candidates for supplementing conventional multiparametric MRI. This study aims to investigate the detection of PCa in fresh ex vivo human prostatectomy specimens using MR elastography. METHODS: Fourteen fresh prostate specimens from men with clinically significant PCa without formalin fixation or prior radiation therapy were examined by MR elastography at 500 Hz immediately after radical prostatectomy in a 9.4T preclinical scanner. Specimens were divided into 12 segments for both calculation of storage modulus (G' in kilopascals) and pathology (Gleason score) as reference standard. Sensitivity, specificity, and area under the receiver operating characteristic curve were calculated to assess PCa detection. RESULTS: The mean G' and SD were as follows: all segments, 8.74 ± 5.26 kPa; healthy segments, 5.44 ± 4.40 kPa; and cancerous segments, 10.84 ± 4.65 kPa. The difference between healthy and cancerous segments was significant with P ≤ .001. Diagnostic performance assessed with the Youden index was as follows: sensitivity, 69%; specificity, 79%; area under the curve, 0.81; and cutoff, 10.67 kPa. CONCLUSION: Our results suggest that prostate MR elastography has the potential to improve diagnostic performance of multiparametric MRI, especially regarding its 2 major limitations: interobserver variability and low specificity. Particularly the high value for specificity in PCa detection is a stimulating result and encourages further investigation of this method.
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Técnicas de Imagem por Elasticidade , Neoplasias da Próstata , Humanos , Imageamento por Ressonância Magnética , Masculino , Prostatectomia , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/cirurgia , Sensibilidade e EspecificidadeRESUMO
PURPOSE: We compared intraoperative and perioperative outcomes between extraperitoneal and transperitoneal radical prostatectomy performed using a "purpose-designed" single port robotic platform. MATERIALS AND METHODS: A total of 98 patients underwent single port robotic prostatectomy using the da Vinci SP® robotic system with extraperitoneal (group I, 52) vs transperitoneal (group II, 46) approach. Demographics and perioperative data including postoperative recovery outcomes were recorded and compared between the 2 groups. RESULTS: Groups were similar in terms of demographics and prostate cancer risk category. Mean operative time (201±37.5 vs 248.2±42.3 minutes, p <0.00001) as well as median postoperative hospital stay (4.3 vs 25.7 hours p <0.0001) was significantly shorter with the extraperitoneal approach. Overall need for pain medications or narcotics as well as the required amount of narcotics per patient (if administered) were significantly lower with the extraperitoneal approach. Extraprostatic extension was detected in 48.1% vs 41.3% of patients in groups I and II, respectively. Surgical margins were positive in 26.9% in group I vs 41.3% in group II (p=0.13). More than 80% of patients with positive surgical margins had high risk features on final surgical pathology. The 90-day continence rate was similar between the 2 groups (60% vs 62.5%, p=0.82). CONCLUSIONS: Extraperitoneal and transperitoneal single port robotic radical prostatectomy are safe and feasible approaches. The extraperitoneal approach is associated with a significantly shorter postoperative hospital stay and decreased need for postoperative narcotics. Randomized trials with adequate sample size and postoperative followup are advisable for further evaluation of the outcomes to clarify patient selection criteria for each approach.
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Peritônio/cirurgia , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Humanos , Masculino , Estudos Prospectivos , Prostatectomia/instrumentação , Procedimentos Cirúrgicos Robóticos/instrumentação , Resultado do TratamentoRESUMO
INTRODUCTION: The da Vinci Single-Port (SP) platform (Intuitive Surgical Inc, Sunnyvale CA) is a recently approved robotic surgical platform which features several novel modifications from previously available single trocar models including a flexible camera, articulating instruments, and navigator guidance for real-time monitoring of instrument position. We sought to describe our clinical experience with this device as well as to review the current literature related to the use of the SP platform. METHODS: We provide a narrative review of clinical data related to single-port robotic surgery within the field of urology. In addition, we report our initial clinical experience for surgical procedures performed with the SP platform between December 2018 and April 2019 following installation of the system at our institution. RESULTS: Currently, the presently available literature for single-port robotic urological surgery consists of single-center case reports and series. Most major robotic urologic operations appear technically feasible using the da Vinci SP platform; however, additional multi-center studies and randomized trials are needed to determine what role the SP platform will play. CONCLUSIONS: Rather than an iterative step or a niche system, the SP platform provides for a new approach to single-site laparoscopic or robotic techniques and is demonstrated as a feasible approach for several major robotic urological operations. While comparative studies will be required to evaluate perioperative and long-term outcomes between SP and multi-port platforms, further technological advances will continue to push surgeons towards less morbid and more minimally invasive approaches for surgery.
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Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Robóticos , Procedimentos Cirúrgicos Urológicos/métodos , Desenho de Equipamento , Humanos , Procedimentos Cirúrgicos Robóticos/instrumentaçãoRESUMO
PURPOSE: To compare the outcomes of PN to those of RN in very elderly patients treated for clinically localized renal tumor. PATIENTS AND METHODS: A purpose-built multi-institutional international database (RESURGE project) was used for this retrospective analysis. Patients over 75 years old and surgically treated for a suspicious of localized renal with either PN or RN were included in this database. Surgical, renal function and oncological outcomes were analyzed. Propensity scores for the predicted probability to receive PN in each patient were estimated by logistic regression models. Cox proportional hazard models were estimated to determine the relative change in hazard associated with PN vs RN on overall mortality (OM), cancer-specific mortality (CSM) and other-cause mortality (OCM). RESULTS: A total of 613 patients who underwent RN were successfully matched with 613 controls who underwent PN. Higher overall complication rate was recorded in the PN group (33% vs 25%; p = 0.01). Median follow-up for the entire cohort was 35 months (interquartile range [IQR] 13-63 months). There was a significant difference between RN and PN in median decline of eGFR (39% vs 17%; p < 0.01). PN was not correlated with OM (HR = 0.71; p = 0.56), OCM (HR = 0.74; p = 0.5), and showed a protective trend for CSM (HR = 0.19; p = 0.05). PN was found to be a protective factor for surgical CKD (HR = 0.28; p < 0.01) and worsening of eGFR in patients with baseline CKD. Retrospective design represents a limitation of this analysis. CONCLUSIONS: Adoption of PN in very elderly patients with localized renal tumor does not compromise oncological outcomes, and it allows better functional preservation at mid-term (3-year) follow-up, relative to RN. Whether this functional benefit translates into a survival benefit remains to be determined.
Assuntos
Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Estadiamento de Neoplasias , Nefrectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Fatores Etários , Idoso , Ásia/epidemiologia , Carcinoma de Células Renais/diagnóstico , Carcinoma de Células Renais/fisiopatologia , Europa (Continente)/epidemiologia , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Neoplasias Renais/diagnóstico , Neoplasias Renais/fisiopatologia , Masculino , Pessoa de Meia-Idade , América do Norte/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do TratamentoRESUMO
The da Vinci single port (SP) robotic system (Intuitive Surgical, Sunnyvale, CA, USA) is a recently approved robotic platform designed with several modifications to the previously available multi-port robotic systems. This article describes the technique performed utilizing the SP robotic system for radical robotic-assisted laparoscopic prostatectomy (RALP) with or without bilateral pelvic lymph node dissection from a single institution. In this report we describe our step-by-step approach, technical modifications from the multi-port technique and initial results for performing single port robotic-assisted laparoscopic prostatectomy (SP-RALP). We describe our initial experience and technique with the SP robotic system consisting of 23 consecutive patients who underwent SP-RALP between December 2018 and May 2019. The median patient age was 62 years with approximately half of the patients undergoing pelvic lymphadenectomy. The median operative time was 236 minutes, median estimated blood loss was 50 mL and median length of hospital stay was 1 day. No unplanned port placements occurred and no conversions to open surgery occurred. We demonstrate the safety and feasibility of performing a transperitoneal prostatectomy with either a posterior or anterior approach.
Assuntos
Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/instrumentação , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Estudos de Coortes , Desenho de Equipamento , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: To assess the safety and feasibility of the da Vinci® SP (Intuitive Surgical, Sunnyvale, CA, USA) robotic platform for a consecutive series of patients who underwent single-port robot-assisted laparoscopic radical prostatectomy (SP-RALP). PATIENTS AND METHODS: In all, 10 consecutive patients with biopsy confirmed prostate cancer underwent SP-RALP at our institution. Pre-, peri-, and postoperative data were prospectively collected for key outcomes including: estimated blood loss (EBL), operative time, postoperative pain requirements, duration of hospital stay, and complications. RESULTS: The patients were aged 52-77 years with a body mass index of 24.4-36.7 kg/m2 . Prostate volumes ranged from 26 to 136 mL, with a mean (sd) PSA (prostate specific antigen) level of 11.0 (10.6) ng/mL. Lymph node dissection was performed in four patients and nerve sparing in five. No intraoperative complications occurred, and no patients required conversion to an open approach. Total EBL was 20-150 mL, with a median (interquartile range [IQR]) console time of 189 (171-207) min and operative time of 234 (216-247) min. No patients were readmitted or required intervention. Urethral catheters were removed at a median (IQR) of 10 (8-11) days after surgery. CONCLUSION: SP-RALP appears to be a safe and feasible approach to performing robotic radical prostatectomy. Long-term follow-up will be necessary to assess initial oncological and functional results.
Assuntos
Próstata/cirurgia , Prostatectomia , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos , Idoso , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Prospectivos , Prostatectomia/efeitos adversos , Prostatectomia/métodos , Prostatectomia/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Resultado do TratamentoRESUMO
OBJECTIVES: To compare the perioperative and short-term outcomes of robotic pyelolithotomy (RP) and laparoscopic pyelolithotomy (LP) for the treatment of renal stones. MATERIALS AND METHODS: We retrospectively evaluated 39 patients who underwent robotic or laparoscopic pyelolithotomy from January 2015 to December 2018. RESULTS: The preoperative characteristics of the two groups were comparable. The mean operative time was 173 ± 51 and 182 ± 62 min in the RP and LP groups, respectively (p=0.6). Blood loss and length of hospital stay with the robotic approach were lower than those with the laparoscopic approach (210 ± 180 ml vs. 639 ± 412 ml, p<0.001, and 3.8 ± 3 days vs. 7.3 ± 2.8 days, p=0.001). A complete stone-free status was achieved in 17 (85%) patients in the RP group and 8 (42%) in the LP group (p=0.01). Post-operative complications with the two approaches were also similar. CONCLUSIONS: In some selected cases, laparoscopic and robotic pyelolithotomy are alternative procedures for large, multiple and complex kidney stones. The robotic approach was associated with less intraoperative blood loss and fewer days of hospitalization compared to the laparoscopic method, and also gives a better stone-free rate.