Robotic versus open radical cystectomy throughout the learning phase: insights from a real-life multicenter study.

BACKGROUND AND OBJECTIVES: Robot-assisted radical cystectomy (RARC) has been shown to be non-inferior to open radical cystectomy (ORC) for the treatment of bladder cancer (BC). However, most data on RARC come from high-volume surgeons at high-volume centers. The objective of the study was to compare perioperative and mid-term oncologic outcomes of RARC versus ORC in a real-life cohort of patients treated by surgeons starting their experience with RARC. MATERIALS AND METHODS: Data were prospectively collected from consecutive patients undergoing RARC and ORC at five referral Centers between 2010 and 2016 by five surgeons (one per center) with no prior experience in RARC. Patients with high-risk non-muscle-invasive or organ-confined muscle-invasive (T2N0M0) bladder cancer were considered for RARC. The main study endpoints were perioperative outcomes, postoperative surgical complications, and mid-term oncologic outcomes. RESULTS: Overall, 124 and 118 patients underwent RARC and ORC, respectively. Baseline patients' and tumors' characteristics were comparable between the two groups. Yet, the proportion of patients receiving neoadjuvant chemotherapy was significantly higher in the RARC cohort. Median operative time was significantly higher, while median EBL, LOH, and transfusion rates were significantly lower after RARC. Median number of lymph nodes removed was significantly higher after RARC. All other histopathological outcomes, as well as the rate of early (< 30 days) and late postoperative complications, were comparable to ORC. At a median follow-up of 2 years, 29 (23%) and 41 (35%) patients developed disease recurrence (p = 0.05), while 20 (16%) and 37 (31%) died of bladder cancer (p = 0.005) after RARC and ORC, respectively. CONCLUSIONS: With proper patient selection, RARC was non-inferior to ORC throughout the surgeons' learning phase. Yet, the observed differences in oncologic outcomes suggest selection bias toward adoption of RARC for patients with more favorable disease characteristics.

Perioperative outcomes and complications of intracorporeal vs extracorporeal urinary diversion after robot-assisted radical cystectomy for bladder cancer: a real-life, multi-institutional french study.

PURPOSE: To compare perioperative outcomes and complications of extracorporeal (ECUD) vs intracorporeal urinary diversion (ICUD) in patients after undergoing robot-assisted radical cystectomy (RARC) at five referral centers in France. METHODS: We retrospectively reviewed our multi-institutional, prospectively-collected database to select patients undergoing RARC between 2010 and 2016 with at least 3 months of follow-up. At each center, the surgery was performed by one surgeon with extensive experience in robotic surgery and radical cystectomy but no prior experience in RARC. RESULTS: Overall, 108 patients were included. ECUD and ICUD were performed in 34 (31.5%) and 74 (68.5%) patients, respectively. Patient characteristics were comparable among the two groups, except for a higher proportion of patients with high surgical risk (ASA score ≥ 3) in the ECUD group. Ileal conduit and ileal neobladder were performed in 63/108 (58%) and 45/108 (42%) cases, respectively. Ileal conduit was performed more often with an extracorporeal approach while ileal neobladder with an intracorporeal approach. Overall, operative time, length of hospital stay, positive margin rate, and number of lymph nodes removed did not significantly differ among the two cohorts. Estimated blood loss and transfusion rates were significantly higher in the ECUD group. Rate of early (38.2 vs 47.3%, p = 0.4) and late (29.4 vs 18.9%, p = 0.2) surgical complications did not significantly differ between the ECUD and ICUD groups. Results were comparable in the subgroup analysis in the ileal conduit subpopulation. CONCLUSION: In our real-life, multi-institutional study, RARC with ICUD achieved perioperative outcomes and complication rates comparable to those of RARC with ECUD.

Impact of elective versus imperative indications on oncologic outcomes after open nephron-sparing surgery for the treatment of sporadic renal cell carcinomas.

PURPOSE: To determine the effect of nephron-sparing surgery (NSS) on cancer control in renal cell carcinomas (RCC) and to compare the outcomes of patients who had elective versus imperative indications for surgery. METHODS: We performed a retrospective review of the data for patients treated with open NSS between 1980 and 2005 for sporadic RCCs. The following data were analyzed: age, intraoperative parameters, tumor size, Fuhrman grade, tumor, node, metastasis system disease stage, pathological data, and outcome. RESULTS: A total of 155 patients with a median age of 60 years were included. The mean preoperative and postoperative creatinine levels were 1.1 ± 0.3 mg/dl (range 0.6-2.6 mg/dl) and 1.2 ± 0.4 mg/dl (range 0.5-3.4 mg/dl), respectively. The mean tumor size was 3.8 ± 2 cm (range 1-10 cm). Margin status was positive in 15 cases (9.70%), and multifocal RCCs were observed in 36 patients (23.2%). Overall, NSS indications were elective in 96 cases (61.9%) and imperative in 59 cases (38.1%). Univariate analysis found that elective cases were associated with better perioperative outcomes (P = 0.01). In univariate analysis, tumor, node, metastasis system disease stage, multifocality, and indication were associated with recurrence (P < 0.05). In the multivariate analysis, only multifocality status and imperatives indications were significant (P < 0.05). The mean follow-up was 118.2 ± 151 months. The 5- and 10-year tumor-free survival rates were 81.8% and 78.7% in elective and imperatives cases, respectively. CONCLUSIONS: Oncologic control seems to be better for cases of elective open NSS. Thus, NSS should be advocated as soon as it is technically possible, regardless of the size of the tumor.

[Palliative treatment of symptomatic benign prostatic hyperplasia by permanent urethral stent (Ultraflex, Boston Scientific) in high surgical risk patients]. / Traitement palliatif de l'hyperplasie bénigne prostatique symptomatique par prothése endo-uréthrale permanente (Ultraflex, Boston Scientific) chez les patients a haut risque chirurgical.

OBJECTIVE: To evaluate the medium-term and long-term results of treatment of symptomatic benign prostatic hyperplasia (BPH) by permanent transprostatic urethral stenting in high surgical risk patients. MATERIALS AND METHODS: Single-centre retrospective study on 19 consecutive patients with a mean age of 79.5 years (range: 61-96) treated by nitinol permanent urethral stent (Boston Scientific Corp.) from December 1995 to July 2006 for bladder neck obstruction. All patients presented a major contraindication (ASA III or IV) to immediate conventional surgical management. Stenting was performed under endourethral Xylocaine gel local anaesthesia. Fourteen patients presented acute urinary retention and 4 had chronic obstructive renal failure. One patient with an indwelling catheter had a history of recurrent acute prostatitis. The functional results were assessed by resumption of voiding, determination of post-voiding residual volume, serum creatinine and presence or absence of symptomatic urinary tract infection. The anatomical assessment was performed by voiding and retrograde cystourethrography and urethral endoscopy. RESULTS: This series of 19 patients had a mean follow-up of 20 months (1-62). No intraoperative complication was observed. Resumption of voiding was achieved immediately postoperatively in 18 patients. One patient required more prolonged urinary drainage before voiding was restored. No cases of stent migration were observed. Postoperative serum creatinine was stable. Post-voiding residual volume was less than 100 ml in fifteen patients and less than 200 ml in four patients. One patient was explanted. CONCLUSION: The treatment of bladder neck obstruction by permanent urethral stenting is an alternative to surgery for patients considered to be temporarily or permanently inoperable. This indication remains exceptional, but should be kept in mind in view of the satisfactory medium-term results to associated with a low morbidity for a procedure performed exclusively under local anaesthesia.