Long-Term Oncological and Functional Outcomes After Robot-Assisted Partial Nephrectomy for Clinically Localized Renal Cell Carcinoma.

BACKGROUND: To evaluate long-term oncological and renal function outcomes in patients treated with robot-assisted partial nephrectomy (RAPN) for renal cell carcinoma (RCC). PATIENTS AND METHODS: Patients undergoing RAPN for clinically localized RCC between January 2014 and December 2019 at a tertiary robotic reference center were evaluated. Clinical course, pathologic characteristics, and long-term outcomes were obtained from our institutional review board-approved RCC database. RESULTS: A total of 234 patients were available for analysis. Median follow-up was 46 months (10.8-97.8 months), with 77 patients (32.9%) having at least 5-years of follow-up. Pathology revealed clear-cell RCC in 67.5% (n = 158). Among unfavorable factors, nuclear grades 3 or 4 were found in 67 (29.4%), lymphovascular invasion in 10 (4.3%), positive surgical margins in 22 (9.4%), necrosis in 21 (9%), and sarcomatoid pattern in 2 patients (0.9%). At 12 months, mean serum creatinine was 1.04 mg/dL and 12.9% of patients experienced upstaging in chronic kidney disease. Overall recurrence-free survival at 5-years was 97.8%. There were five local (2.1%) and two distant (0.9%) recurrences, none of them resulting in cancer-specific death. Median time to recurrence was 20 months (11-64 months). Warm ischemia time [hazard ratio (HR) = 1.14, p = 0.034] and sarcomatoid pattern (HR = 124.57, p = 0.001) were the only variables associated with local relapse. CONCLUSIONS: Data from this large cohort demonstrate that patients undergoing RAPN have a low incidence of local and distant relapse, resulting in excellent long-term survival while preserving stable renal function in most patients.

Management of patients who opt for radical prostatectomy during the coronavirus disease 2019 (COVID-19) pandemic: an international accelerated consensus statement.

OBJECTIVE: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. The objective of this work is to develop guidance on criteria for prioritisation of surgery and reconfiguring management pathways for patients with non-metastatic prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve a low likelihood of coronavirus disease 2019 (COVID-19) hazard if radical prostatectomy (RP) was to be carried out during the outbreak and whilst the disease is endemic. METHODS: We conducted an accelerated consensus process and systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n = 34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. The Consensus opinion was defined as ≥80% agreement and this was used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and measures developed to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritisation criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as 'COVID-19 cold' sites. CONCLUSION: Reconfiguring management pathways for patients with prostate cancer is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing RP within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

Setting up a pediatric robotic urology program: A USA institution experience.

Implementing a robotic urological surgery program requires institutional support, and necessitates a comprehensive, detail-oriented plan that accounts for training, oversight, cost and case volume. Given the prevalence of robotic surgery in adult urology, in many instances it might be feasible to implement a pediatric robotic urology program within the greater context of adult urology. This involves, from an institutional standpoint, proportional distribution of equipment cost and operating room time. However, the pediatric urology team primarily determines goals for volume expansion, operative case selection, resident training and surgical innovation within the specialty. In addition to the clinical model, a robust economic model that includes marketing must be present. This review specifically highlights these factors in relationship to establishing and maintaining a pediatric robotic urology program. In addition, we share our data involving robot use over the program's first nine years (December 2007-December 2016).

Impact of insufflator/aspirator versus exclusive insufflator during robotic radical prostatectomy: a comparative prospective cohort study.

New generation devices that combine high-flow insufflation with smoke aspiration using continuous gas recirculation ]so-called Insufflator/aspirator systems (IAS)] have recently been developed to generate pneumoperitoneum. The use of an IAS could have an impact on surgical compared to conventional insufflation systems (CIS). The present study aimed to compare the clinical effectiveness/safety, healthorganizational, and pathological/oncological outcomes of the CIS versus IAS during robot-assisted radical prostatectomy (RARP). Methods: Comparative retrospective cohort study including patients with non-metastatic prostate cancer treated with RARP by four expert surgeons at a robotic referral centre between January 2020 and December 2021. A CIS was used until 15 March 2021, and the IAS thereafter. Data were extracted from the Institutional Review Board-approved (#1064) retro and prospective institutional database. Results: The final analysis included 299 patients (143 CIS; 156 IAS). We found no statistically significant differences in demographic data and preoperative results, allowing adequate group comparison. The rate of complications of any degree (9.1% and 1.9%, P<0.05) and major complications (4.2% and 0.6%, P<0.05) were lower in the IAS group. Accordingly, the hospital stay was shorter in the IAS group (P<0.05); however, the small size of this statistically significant difference probably lacks clinical value (1.9±1.6 vs. 1.6±0.8 days). There was no significant difference in surgical time, bleeding, pathological findings, or oncological results. Conclusions: Data from this large group of patients showed that the rate of overall complications, the rate of major complications, and the length of stay were lower in the IAS group. Implementing the IAS in RARP patients increased the occurrence of SCE and affected our daily practice of transversus abdominis plane block. Interpretation of the results should be made with caution since the design of this study did not allow for the identification of a causal relationship.

Robotic paediatric urology.

UNLABELLED: What's known on the subject? and What does the study add? Robot assisted laparoscopic surgery (RALS) is slowly gaining acceptance in the field of paediatric urology. Accumulating data on safety and efficacy when performing paediatric robotic urologic procedures has led paediatric urologists to gradually embrace increasingly more complex reconstructive surgeries. Indeed, the unique and delicate movements generated by the robotic system make this technology ideal for children who often require reconstructive procedures. We critically review the current role of RALS in paediatric urology and to analyse the published data, with a special emphasis on the most common applications. We also propose a structured plan to expedite training and the surgical 'learning curve'. OBJECTIVES: To critically review the current role of robot-assisted laparoscopic surgery (RALS) in paediatric urology and to analyse the published data, with a special emphasis on the most common applications. One of the greatest benefits of RALS has been the ability to truly spread the application of minimally invasive surgery to paediatric surgical patients. The unique attributes of the robotic interface make this technology ideal for children with congenital anomalies, who often require reconstructive procedures. We also propose a structured plan to expedite training and the surgical 'learning curve'. PATIENTS AND METHODS: Currently, almost all urological surgical procedures in children have been performed with the assistance of the robotic interface. The most commonly performed procedures include pyeloplasty, nephrectomy/hemi-nephrectomy and surgery for vesico-ureteric reflux. Initial series of bladder augmentation and appendicovesicostomy are available. RESULTS: Initial results with RALS are encouraging and have shown safety similar to open procedures, and outcomes at least equivalent to standard laparoscopy. Accumulating data have consistently shown that postoperative analgesia requirements and overall hospital stay are decreased. However, operative durations are significantly longer than their open counterparts, but this is decreasing as experience accumulates. CONCLUSIONS: RALS is already part of paediatric urological surgery. Larger single-institution case series and comparative studies with the open approach and multi-institutional meta-analyses will help to identify the benefits of RALS in paediatric urology.

Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-urethral anastomosis.

OBJECTIVES: To describe a technical modification during robotic-assisted simple prostatectomy (RASP) aiming to decrease perioperative blood loss, shorten the length of hospital stay and eliminate the need of postoperative continuous bladder irrigation. To describe perioperative outcomes, pathological findings and functional outcomes of our single-surgeon series using this technique. METHODS: We analysed six consecutive patients who underwent RASP using our technical modification between February and September 2010. Transrectal ultrasonography (TRUS) guided prostate biopsy was performed in all cases and revealed benign prostatic hyperplasia in two cases and benign prostatic hyperplasia plus chronic prostatitis in four cases. The mean estimated prostate volume in the TRUS was 157 ± 74 (range 90-300) mL and the average preoperative International Prostate Symptom score was 19.8 ± 9.6 (10-32). Two patients were in urinary retention before surgery. Our technique of RASP includes the standard operative steps reported during open and laparoscopic simple prostatectomy; however, with the addition of some technical modifications during the reconstructive part of the procedure. Following the resection of the adenoma, instead of performing the classical 'trigonization' of the bladder neck and closure of the prostatic capsule, we propose three modified surgical steps: plication of the posterior prostatic capsule, a modified van Velthoven continuous vesico-urethral anastomosis and, finally, suture of the anterior prostatic capsule to the anterior bladder wall. RESULTS: The patients' average age was 69 ± 4.9 (63-74) years; the mean estimated blood loss was 208 ± 66 (100-300) mL and the mean operative time was 90 ± 17.6 (75-120) min. All patients were discharged on postoperative day 1 without the need of continuous bladder irrigation at any time after RASP. No blood transfusion or perioperative complications were reported. The mean weight of the surgical specimen was 145 ± 41.6 (84-186) g. Histopathological evaluation revealed benign prostatic hyperplasia plus chronic prostatitis in five patients and prostatic adenocarcinoma (Gleason score 3+3, pT1a) with negative surgical margins in one patient. The mean serum prostate-specific antigen level decreased from 7 ± 2.5 (4.2-11) ng/mL preoperatively to 1.05 ± 0.8 (0.2-2.5) after RASP. Significant improvement from baseline was reported in the average International Prostate Symptom score (average preoperative vs postoperative, 19.8 ± 9.6 vs 5.5 ± 2.5, P= 0.01) and in mean maximum urine flow (average preoperative vs postoperative 7.75 ± 3.3 vs 19 ± 4.5 mL/s, P= 0.019) at 2 months after RASP. All patients were continent (defined as the use of no pads) at 2 months after RASP. CONCLUSIONS: Our modified technique of RASP is a safe and feasible option for treatment of lower urinary tract symptoms caused by large prostatic adenomas. Potential advantages of our technique include reduced blood loss, lower blood transfusion rates and shorter length of hospital stay with no need of postoperative continuous bladder irrigation. Larger series with longer follow-up are necessary to determine long-term outcomes in comparison to open simple prostatectomy or to the standard technique of RASP.

Intranodal Ultrasound-Guided Percutaneous Methylene Blue Injection for the Identification of Leakage Point during Laparoscopic Repair of Refractory Chylous Ascites after Laparoscopic Lymphadenectomy for Kidney Cancer.

Chylous ascites is an uncommon complication after surgery that can result in malnutrition and immunodeficiency. Therefore, surgical interventions are reserved for refractory patients, and the primary success factor for these interventions is locating the point of leakage, which is often tricky. We describe a case of a 56-year-old male with chylous ascites after laparoscopic radical nephrectomy and lumbo-aortic lymphadenectomy for kidney cancer. The patient was initially managed with dietary modifications and drainage placement. Afterward, lymphography with Lipiodol, percutaneous embolization of the leakage point, and total parenteral nutrition were established. Finally, the patient underwent laparoscopic repair after identifying the leakage point by injecting methylene blue through an inguinal node. Complete resolution was achieved, and no complications related to the procedure were recorded. Intranodal methylene blue injection can be an invaluable tool to identify the point of leakage in selected patients to improve the outcomes of surgical repair of refractory chylous ascites.

Positive surgical margins after robotic assisted radical prostatectomy: a multi-institutional study.

PURPOSE: Positive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies. MATERIALS AND METHODS: We analyzed the records of 8,418 patients who underwent robotic assisted radical prostatectomy at 7 institutions. Of the patients 323 had missing data on margin status. Positive surgical margins were categorized into 4 groups, including apex, bladder neck, posterolateral and multifocal. The records of 6,169 patients were available for multivariate analysis. The variables entered into the logistic regression models were age, body mass index, preoperative prostate specific antigen, biopsy Gleason score, prostate weight and pathological stage. A second model was built to identify predictive factors for positive surgical margins in the subset of patients with organ confined disease (pT2). RESULTS: The overall positive surgical margin rate was 15.7% (1,272 of 8,095 patients). The positive surgical margin rate for pT2 and pT3 disease was 9.45% and 37.2%, respectively. On multivariate analysis pathological stage (pT2 vs pT3 OR 4.588, p<0.001) and preoperative prostate specific antigen (4 or less vs greater than 10 ng/ml OR 2.918, p<0.001) were the most important independent predictive factors for positive surgical margins after robotic assisted radical prostatectomy. Increasing prostate weight was associated with a lower risk of positive surgical margins after robotic assisted radical prostatectomy (OR 0.984, p<0.001) and a higher body mass index was associated with a higher risk of positive surgical margins (OR 1.032, p<0.001). For organ confined disease preoperative prostate specific antigen was the most important factor that independently correlated with positive surgical margins (4 or less vs greater than 10 ng/ml OR 3.8, p<0.001). CONCLUSIONS: The prostatic apex followed by a posterolateral site was the most common location of positive surgical margins after robotic assisted radical prostatectomy. Factors that correlated with cancer aggressiveness, such as pathological stage and preoperative prostate specific antigen, were the most important factors independently associated with an increased risk of positive surgical margins after robotic assisted radical prostatectomy.

Incidence of lymphoceles after robot-assisted pelvic lymph node dissection.

OBJECTIVE: • To determine the incidence and predictive factors of lymphocele formation in patients undergoing pelvic lymph node dissection (PLND) during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: • Between April and December 2008, 76 patients underwent PLND during RARP for ≥cT2c, prostate-specific antigen level ≥10, Gleason score ≥7 prostate cancer. • All patients were prospectively followed up with pelvic computed tomography 6-12 weeks after the procedure. • All patients received s.c. heparin preoperatively and postoperatively. PLND was limited to zones 1 and 2 as defined by Studer. • Plasma-kinetic bipolar forceps were used for haemostasis during PLND. RESULTS: • At a mean follow-up of 10.8 weeks, 51% (39/76) of patients had developed a lymphocele. Of these 39 lymphoceles 32 (82%) were unilateral and seven (18%) were bilateral. • The mean (range) lymphocele size was 4.3 × 3.2 (1.5-12.3) cm; 41% of lymphoceles were <4 cm, 53.9% were 4-10 cm, and 5.1% were >10 cm in diameter. Six of the 39 lymphoceles (15.4%) were clinically symptomatic. The symptoms were as follows: pelvic pressure in five patients, abdominal distension with ileus in three patients, leg pain/weakness in one patient and costovertebral tenderness in one patient. Two lymphoceles required intervention. • On the logistic regression model the presence of nodal metastases, tumour volume in the prostate specimen and extracapsular extension (ECE) were independent risk factors for the development of a lymphocele. • There was no correlation between estimated blood loss, body mass index, pathological Gleason score or number nodes dissected and the presence of lymphocele. CONCLUSIONS: • The incidence of lymphoceles was higher than anticipated given the believed protective effect of the transperitoneal approach against lymphocele formation. • The risk of lymphocele seemed to increase linearly with the presence of more extensive disease, particularly ECE and nodal involvement. • The benefit of PLND during RARP should be weighed against the elevated risk of lymphocele formation and its potential complications.

Complex robotic reconstructive surgical procedures in children with urologic abnormalities.

PURPOSE OF REVIEW: Robot-assisted laparoscopic surgery (RALS) is evolving rapidly in the pediatric surgical field. The unique attributes of the robotic interface makes this technology ideal for children with congenital anomalies who often require reconstructive procedures. Furthermore, the system can generate extremely delicate movements in a confined working space such as the one generally found in the pediatric population. Herein, we critically review the current experience with RALS placing a special emphasis in children undergoing complex reconstructive surgical procedures worldwide. RECENT FINDINGS: A total of 42 original manuscripts on a variety of robot-assisted urologic surgical procedures in children were identified from a MEDLINE database search. Complex reconstructive procedures that are being currently performed include reoperative pyeloplasty, pyeloplasty in infants, pyelolithotomy, ureteropyelostomy/ureterostomy, bladder augmentation with or without appendico-vesicostomy, bladder neck sling procedure, among others. SUMMARY: Initial results with robot assistance are encouraging and have demonstrated safety comparable to open procedures and outcomes at least equivalent to standard laparoscopy. Future development of smaller instruments, incorporating tactile feedback, will likely overcome current limitations and spread out the use of this technique in younger children and more advanced procedures.

Totally intracorporeal robot-assisted urinary diversion for bladder cancer (Part 1). Review and detailed characterization of ileal conduit and modified Indiana pouch.

OBJECTIVE: To review the most used robot-assisted cutaneous urinary diversion (CUD) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new consistent images. METHODS: A non-systematic review of the literature with the keywords "bladder cancer", "cutaneous urinary diversion", and "radical cystectomy" was performed. RESULTS: Twenty-four studies of intracorporeal ileal conduit (ICIC) and two of intracorporeal Indiana pouch (ICIP) were included in the analysis. Regarding ICIC, the patients' age ranged from 60 to 76 years. The operative time to perform a urinary diversion ranged from 60 to 133 min. The total estimated blood loss ranged from 200 to 1 117 mL. The rate of positive surgical margins ranged from 0% to 14.3%. Early minor and major complication rates ranged from 0% to 71.4% and from 0% to 53.4%, respectively. Late minor and major complication rates ranged from 0% to 66% and from 0% to 32%, respectively. Totally ICIP data are limited to one case report and one clinical series. CONCLUSION: The most frequent type of CUD is ICIC. Randomized studies comparing the performance of the different types of CUD, the performance in an intra- or extracorporeal manner, or the performance of a CUD versus orthotopic ileal neobladder are lacking in the literature. To this day, there are not enough quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used CUD with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images for each technique.

Totally intracorporeal robot-assisted urinary diversion for bladder cancer (part 2). Review and detailed characterization of the existing intracorporeal orthotopic ileal neobladder.

ABSTRACT: To review the most used intracorporeal orthotopic ileal neobladder (ICONB) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new consistent images. METHODS: We performed a non-systematic review of the literature with the keywords "bladder cancer", "urinary diversion", "radical cystectomy", and "neobladder". RESULTS: Forty studies were included in the analysis. The most frequent type of ICONB was the modified Studer "U" neobladder (70%) followed by the Hautmann "W" modified neobladder (7.5%), the "Y" neobladder (5%), and the Padua neobladder (5%). The operative time to perform a urinary diversion ranged from 124 to 553 min. The total estimated blood loss ranged from 200 to 900 mL. The rate of positive surgical margins ranged from 0% to 8.1%. Early minor and major complication rates ranged from 0% to 100% and from 0% to 33%, respectively. Late minor and major complication rates ranged from 0% to 70% and from 0% to 25%, respectively. CONCLUSION: The most frequent types of ICONB are Studer "U" neobladder, Hautmann "W" neobladder, "Y" neobladder, and the Padua neobladder. Randomized studies comparing the performance of the different types of ICONB, the performance in an intra or extracorporeal manner, or the performance of an ICONB versus ICIC are lacking in the literature. To this day, there are not sufficient quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used ICONB with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images of each technique.

Robot-assisted endoscopic inguinal lymphadenectomy: A review of current outcomes.

OBJECTIVE: To review the role of robot-assisted endoscopic inguinal lymphadenectomy (RAIL) in the management of penile cancer. METHODS: A PubMed search for all relevant publications regarding RAIL series up until August 2019 was performed using the keyword "robotic", "inguinal lymph node dissection", and "penile cancer". Weighted mean was calculated in the largest series for all outcomes using the number of patients included in each study as the weighting factor. RESULTS: We identified 23 articles, of note the three largest series that included 102, 27, and 20 RAIL in 51, 14, and 10 patients, respectively. Saphenous vein was spared in 88.93% of RAIL cases in these series and node yield was 11.42 per groin; 35.28% of patients had positive pathological nodes. The weighted mean of operative time was 87.98 min per RAIL and the estimated blood loss was 37.08 mL per patient. The mean length of hospital stay was 1.29 days and the drain was kept in place for 17.02 days; the major complication rate was only 5.31% in these series. The mean follow-up was 33.46 months with a recurrence-free survival of 96.33%. CONCLUSION: The literature regarding RAIL describes promising results, although it has shorter follow-up and higher costs when compared to historically series from the open approach. Initials series reported lower cutaneous complications compared to conventional approach, without compromising oncological outcomes. However, long-term results and larger trials are crucial to validate those findings.

Robot-assisted retroperitoneal lymphadenectomy: The state of art.

OBJECTIVE: To perform a narrative review about the role of robot-assisted retroperitoneal lymphadenectomy (R-RPLND) in the management of testicular cancer. METHODS: A PubMed search for all relevant publications regarding the R-RPLND series up until August 2019 was performed. The largest series were identified, and weighted means calculated for outcomes using the number of patients included in each study as the weighting factor. RESULTS: Fifty-six articles of R-RPLND were identified and eight series with more than 10 patients in each were included. The weighted mean age was 31.12 years; primary and post chemotherapy R-RPLND were performed in 50.59% and 49.41% of patients. The clinical stage was I, II and III in 47.20%, 39.57% and 13.23% of patients. A modified R-RPLND template was used in 78.02% of patients, while 21.98% underwent bilateral full template. The weighted mean node yield, operative time and estimated blood loss were, respectively, 22.15 nodes, 277.35 min and 131.94 mL. The weighted mean length of hospital stay was 2 days and antegrade ejaculation was preserved in 92.12% of patients. Major post-operative complications (Clavien III or IV) occurred in 5.34%. Positive pathological nodes were detected in 24.54%, while the recurrence free survival was 95.77% with a follow-up of 21.81 months. CONCLUSION: R-RPLND has proven to be a reproducible and safe approach in experienced centers; short-term oncologic outcomes are similar to the open approach with less morbidity and shorter convalescence related to its minimal invasiveness. However, longer follow-up and new trials comparing head-to-head both techniques are expected.

Continence, potency and oncological outcomes after robotic-assisted radical prostatectomy: early trifecta results of a high-volume surgeon.

OBJECTIVE: • To evaluate early trifecta outcomes after robotic-assisted radical prostatectomy (RARP) performed by a high-volume surgeon. PATIENTS AND METHODS: • We evaluated prospectively 1100 consecutive patients who underwent RARP performed by one surgeon. In all, 541 men were considered potent before RARP; of these 404 underwent bilateral full nerve sparing and were included in this analysis. • Baseline and postoperative urinary and sexual functions were assessed using self-administered validated questionnaires. • Postoperative continence was defined as the use of no pads; potency was defined as the ability to achieve and maintain satisfactory erections for sexual intercourse >50% of times, with or without the use of oral phosphodiesterase type 5 inhibitors; Biochemical recurrence (BCR) was defined as two consecutive PSA levels of >0.2 ng/mL after RARP. • Results were compared between three age groups: Group 1, ≤ 55 years, Group 2, 56-65 years and Group 3, >65 years. RESULTS: • The trifecta rates at 6 weeks, 3, 6, 12, and 18 months after RARP were 42.8%, 65.3%, 80.3%, 86% and 91%, respectively. • There were no statistically significant differences in the continence and BCR-free rates between the three age groups at all postoperative intervals analysed. • Nevertheless, younger men had higher potency rates and shorter time to recovery of sexual function when compared with older men at 6 weeks, 3, 6 and 12 months after RARP (P < 0.01 at all time points). • Similarly, younger men had higher trifecta rates at 6 weeks, 3 and 6 months after RARP compared with older men (P < 0.01 at all time points). CONCLUSION: • RARP offers excellent short-term trifecta outcomes when performed by an experienced surgeon. • Younger men had higher overall trifecta rates when compared with older men at 6 weeks, 3 and 6 months after RARP.

Techniques of nerve-sparing and potency outcomes following robot-assisted laparoscopic prostatectomy.

PURPOSE: Nerve sparing radical prostatectomy is the gold standard for the treatment of prostate cancer. Over the past decade, more and more surgeons and patients are opting for a robot-assisted procedure. The purpose of this paper is to briefly review different techniques and outcomes of nerve sparing robot assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: We performed a MEDLINE search from 2001 to 2009 using the keywords "robotic prostatectomy", "cavernosal nerve", "pelvic neuroanatomy", "potency", "outcomes" and "comparison". Extended search was also performed using the references from these articles. RESULTS: Several techniques of nerve sparing are available in literature for RALP, which have been described in this manuscript. These include, "the veil of Aphrodite", "athermal retrograde neurovascular release", "clipless antegrade nerve sparing" and "clipless cautery free technique". The comparative and the non comparative series showing outcomes of RALP have been described in the manuscript. CONCLUSIONS: The basic principles for nerve sparing revolve around minimal traction, athermal dissection, and approaching the correct planes. It has not been documented if any one technique is better than the other. Regardless of technique, patient selection, wise clinical judgment and a careful dissection are the keys to achieve optimal oncological outcomes following RALP.

High intensity focused ultrasound renal tissue ablation: a laparoscopic porcine model.

PURPOSE: High intensity focused ultrasound for renal lesions is still experimental. In a porcine model we evaluated the safety and efficacy of a newly designed laparoscopic high intensity focused ultrasound probe and software that allows real-time ultrasound guidance during renal tissue ablation. MATERIALS AND METHODS: A Sonatherm 600 high intensity focused ultrasound system with a newly designed laparoscopic high intensity focused ultrasound probe was used through a standard Endopath 18 mm port. A total of 16 lesions were created in 15 kidneys in a total of 8 animals and randomized into 2 groups, including acute with sacrifice 4 days postoperatively and subacute with sacrifice 14 days postoperatively. Lesion size and location varied for each surgical procedure to simulate various treatment scenarios. RESULTS: Mean +/- SD planned ablation volume was 7.1 +/- 5.1 cc and mean treatment time was 7.2 +/- 06.88 minutes. For all lesions an injury volume was observed with a central zone of complete necrosis and no viable tissue. Mean total injury volume was 6.5 + 3.5 cc (range 1.1 to 13.7), comparable to preoperative mean planned ablation volume (p = 0.84). Mean necrosis volume was 4.89 +/- 2.9 cc (range 0.8 to 10.5), appreciably lower than preoperative mean planned ablation volume (p = 0.33). Presence of the collecting system interposed with the treatment region did not impact the injury volume-to-planned ablation volume ratio or the necrosis volume-to-planned ablation volume ratio. No animals died before study completion. Two intraoperative complications occurred, including a back wall musculature burn and a ureteral burn. CONCLUSIONS: Laparoscopic high intensity focused ultrasound for renal tissue using the newly developed probe was feasible and efficacious. The ability to perform renal high intensity focused ultrasound through an 18 mm laparoscopic port offers a new alternative for renal tumor ablation.

Serum creatinine can be used as a surrogate for glomerular filtration rate in single renal unit models.

BACKGROUND AND PURPOSE: Single renal unit models are invaluable for studies in renal physiology, transplantation and response to ischemic injury. Glomerular filtration rate (GFR) is commonly used for evaluation of renal function. Measuring the GFR involves relatively complicated and expensive systems. In this study we determined whether serum creatinine (Scr) can predict the GFR in this model. MATERIALS AND METHODS: Right laparoscopic nephrectomy was performed in 46 female pigs weighing 25 kg-30 kg. Twelve days later the left kidney was exposed to various periods of warm ischemia (30, 60, 90, and 120 minutes). Scr and GFR (using the iohexol clearance method) were determined preoperatively and at postoperative days 1, 3, 8, 15, 22 and 29. A total of 244 pairs of Scr and GFR values were analyzed to determine a formula for predicting GFR (pGFR) from Scr. RESULTS: Scr range was 1.2 mg/dl -29 mg/dl and GFR range was 1.8 ml/min -180.5 ml/min. The empiric formula deduced from the database for calculating pGFR from Scr was: pGFR = (217 divided by Scr) minus 0.2. pGFR correlated well with the actual GFR (R(2) = 0.85). The graphs for pGFR were almost indistinguishable from the graphs for actual GFR in every single animal. The results and conclusions of the experiments using either actual or predicted GFR were identical. CONCLUSIONS: We conclude that in a single renal unit porcine model using ischemia as the insult to the kidney, expensive actual measurements of GFR can be reliably replaced by Scr based calculated GFR.

Comparison of laparoscopic and open partial nephrectomy in clinical T1a renal tumors.

PURPOSE: Partial nephrectomy has been established as a standard of care for T(1a) renal tumors. Laparoscopic partial nephrectomy (LPN) has been described as more difficult to perform than open partial nephrectomy (OPN). We compare our series of LPN and OPN. PATIENTS AND METHODS: From October 2002 to January 2006, 76 LPNs were performed for patients with clinical T(1a) tumors. These patients were matched with a cohort of patients who underwent OPN for solitary tumors of 4 cm or smaller in diameter. The cohorts were compared with regard to demographics, perioperative data, and outcomes. RESULTS: The patient populations were demographically similar. Although mean tumor size was smaller in the laparoscopic cohort (2.5 v 2.9 cm, P=0.002), the OPN cohort demonstrated shorter operative (193 v 225 min, P=0.004) and ischemia times (20.5 v 32.8 min). LPN was associated with less blood loss (212 v 385 mL, P<0.001) and shorter hospital stay (2.5 v 5.6 days, P<0.001), however. One positive margin occurred in each of the LPN and OPN cohorts. Intraoperative complications were similar, although LPN was associated with fewer postoperative complications. Of note, two LPN (2.6%) patients had emergent reoperation and complete nephrectomy because of postoperative hemorrhage. CONCLUSIONS: Despite increased operative and ischemia times, LPN patients demonstrated quicker recovery and fewer postoperative complications. Two patients in the LPN group, however, had emergent complete nephrectomy because of hemorrhage. We conclude that LPN is still an evolving alternative to OPN in patients with small renal tumors.

Urinary and sexual function outcomes among different age groups after robot-assisted laparoscopic prostatectomy.

PURPOSE: We present an age-stratified prospective assessment of urinary and sexual function of 300 patients after robot-assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: Subjective assessment data of continence and potency were collected for different age groups (<50, 50-59, and > or =60 years old) preoperatively, and at 1, 3, 6, and 12 months after RALP. Health-related quality of life questionnaires evaluated return of baseline urinary and sexual function at the same time intervals. RESULTS: The three age groups included 21, 129, and 150 patients (aged <50, 50-59, and >60 years old, respectively). Using Kaplan-Meier curves, younger men achieved subjective continence significantly earlier than older age groups when age groups were compared using a 60-year-old cut-off point (P = 0.02). However, subjective continence was noted to be equal among all age groups after 1 year of follow-up. Time to recovery of subjective potency among age groups shows a significant difference in favor of the younger age group (P = 0.01) Objective urinary function is equal between age groups at all time points, while objective sexual function assessment showed a trend toward better results in the younger age group. CONCLUSIONS: Younger men will likely have an earlier return of continence and potency compared to older men after RALP. However, continence outcomes were noted to be equal among age groups after I year of follow-up, while younger men continue to report superior potency outcomes compared to older men over the first postoperative year. Such findings are valuable in counseling older men undergoing this procedure.