Extraperitoneal versus Transperitoneal Single Port Robotic Radical Prostatectomy: A Comparative Analysis of Perioperative Outcomes.

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.

Extraperitoneal single-port robot-assisted radical prostatectomy: initial experience and description of technique.

OBJECTIVE: To describe our technique of extraperitoneal single-port (SP) robot-assisted radical prostatectomy (RARP) and present our clinical experience with the first 10 cases. PATIENTS AND METHODS: In all, 10 consecutive patients diagnosed with localised prostate cancer underwent extraperitoneal SP-RARP using the da Vinci SP® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Exclusion criteria included previous surgery through an infra-umbilical midline incision, prostate size >100 g, or preoperative evidence of extraprostatic disease. All surgeries were performed by a single surgeon with previous experience of >3000 cases in robotic surgery. Demographics and perioperative information were collected including: operative time, estimated blood loss (EBL), complications, length of stay, and days with Foley catheter. The extraperitoneal SP-RARP is performed as follows. Firstly, a 3-cm incision ~2 cm below the umbilicus is made. Dissection of the extraperitoneal space is achieved using a kidney shaped Spacemaker™ balloon (Covidien, Dublin, Ireland), placed through the infra-umbilical incision caudally reaching the retropubic space. Thereafter, the balloon is deployed; the space is created and verified under direct vision with a laparoscopic endoscope. A GelPOINT® mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) is inserted and a dedicated 25-mm multichannel port is placed with a 12-mm accessory laparoscopic port through the gel-seal cap into the same incision. The da Vinci SP surgical platform robot is docked with the patient in a supine position. RARP is performed replicating the technique previously described for multi-arm platforms or transperitoneal SP-RARP. No drain and no additional assistant ports were utilised. RESULTS: The patient's ages ranged between 48 and 70 years, and the mean preoperative prostate-specific antigen (PSA) level was 9 ng/mL. No conversions or intraoperative complications were recorded. The median (interquartile range) operative time was 197.5 (185.5-229.7) min. EBL ranged between 50 and 400 mL, six patients were discharged on the same day as the surgery and the median time with a Foley catheter after surgery was 8 days. CONCLUSIONS: Extraperitoneal SP-RARP is a feasible and safe surgical option to treat localised prostate cancer. In our early experience, promising results and possible advantages were found such as: a small single incision, no additional ports, no Trendelenburg positioning, minimal postoperative pain and use of opioids, and same day discharge. Further investigations need to be done to validate these advantages.

The evolution and resurgence of perineal prostatectomy in the robotic surgical era.

PURPOSE: To review the recent advances in terms of surgical technique and new robotic platforms applied to radical perineal prostatectomy (RPP). METHODS: A literature review was performed focusing on original articles on perineal prostatectomy searching via Medline/Pubmed and Embase. The entire spectrum was covered such as development of surgical technique including pelvic lymphadenectomy, adoption of novel surgical platforms, learning curve and future directions. RESULTS: Surgical removal of the prostate plays a significant role on the treatment of localized prostate cancer (PCa). RPP was the first surgical approach described for radical prostatectomy. This technique declined in popularity secondary to the development of the retropubic approach. Recently, the appearance of novel robotic technology has generated renewed interest in the perineal approach. CONCLUSION: There has been a recent resurgence on the interest of radical perineal prostatectomy for the treatment of localized PCa driven by the advent of new robotic surgical technologies into the field. Future studies are needed to better determine the learning curve of the perineal approach and its current role in the treatment of prostate cancer.

cT1a Renal Masses Less Than 2 versus 2 cm or Greater Managed by Robotic Partial Nephrectomy: A Propensity Score Matched Comparison of Perioperative Outcomes.

PURPOSE: We performed a single center evaluation to compare perioperative, pathological and functional outcomes of robotic partial nephrectomy of T1a renal masses less than vs greater than 2 cm. MATERIALS AND METHODS: Propensity score 1:1 matching of queried patients was performed using the institutional robotic partial nephrectomy database from January 2007 to January 2017. Matching was done by patient age, gender, race, body mass index, the Charlson comorbidity index, smoking status, diabetes, hypertension, hyperlipidemia, ASA® (American Society of Anesthesiologists®) score, estimated glomerular filtration rate, chronic kidney disease stage and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar line and abutting main renal artery or vein) score. We analyzed the records of 524 patients, including 262 with a renal mass less than 2 cm vs 262 with a renal mass 2 cm or greater. Perioperative, pathological and functional outcomes were evaluated. RESULTS: Smaller renal masses (less than 2 cm) were associated with significantly lower operative time, blood loss, ischemia time (mean ± SD 14.3 ± 9.58 vs 21.5 ± 9.51 minutes, p <0.001) and intraoperative transfusions (0% vs 2.7%, p = 0.015). Moreover, we found superior early renal functional outcomes as assessed by the estimated glomerular filtration rate on postoperative day 1 (mean 83.1 ± 21.3 vs 76.6 ± 22.0 mg/ml/1.73 m, p = 0.001), greater parenchymal preservation (mean 89.9% ± 9.45% vs 83.6% ± 8.20%, p <0.001) and a trend toward a lower rate of postoperative complications (13.5% vs 19.5%, p = 0.080). A higher incidence of malignancy was found in larger tumors (85.9% vs 74.8%, p = 0.002) but no difference was recorded in positive surgical margins. CONCLUSIONS: Robotic partial nephrectomy tends to be a low morbidity treatment modality for renal masses less than 2 cm. Although active surveillance is a common option for such tumors, robotic partial nephrectomy remains an alternative in select patients.

Step-by-step technique for single-port robot-assisted radical cystectomy and pelvic lymph nodes dissection using the da Vinci® SP™ surgical system.

OBJECTIVES: To describe a step-by-step technique for robot-assisted radical cystectomy (RARC) with pelvic lymph node dissection (PLND) performed using the da Vinci® SP™ surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). PATIENTS AND METHODS: Four consecutive patients diagnosed with urothelial carcinoma of the bladder were counselled for RARC with PLND and ileal conduit urinary diversion performed using the da Vinci SP surgical system. A 3-cm midline incision was made 5-cm above the umbilicus. Dissection was performed to access the abdominal cavity. Insertion of the GelPOINT® advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) with the SP Cannula was performed through the incision made. A 12-mm AirSeal® (SurgiQuest Inc., Milfort, CT, USA) port for the assistant was placed on the pre-marked stoma site, where an ileal conduit urinary diversion was desired. Demographics and perioperative outcomes were collected under Institutional Review Board approval (IRB 13-780). The surgeries were performed by reproducing the steps of the institutional approach for RARC performed with the multi-arm robotic platform. RESULTS: The surgeries were successfully completed. There was neither conversion to standard multi-arm robotic or open approaches nor the need for additional port placement. The mean (range) operative time was 454 (420-496) min. Blood loss averaged 312 mL. No transfusions were required and no intraoperative complications occurred. All patients had negative surgical margins. All patients were discharged on postoperative day 5. CONCLUSION: From our preliminary experience, RARC with PLND and ileal conduit urinary diversion is feasible and safe using the da Vinci SP surgical system. Further comparative studies with open and multi-arm robotic approaches are warranted.

Robot-assisted surgery for benign distal ureteral strictures: step-by-step technique using the SP® surgical system.

OBJECTIVES: To describe the step-by-step techniques for robot-assisted ureteric reimplantation performed using the Vinci SP® surgical system (Intuitive Surgical, Sunnyvale, CA, USA), including different case scenarios with an educational purpose. MATERIALS AND METHODS: Three consecutive patients diagnosed with distal benign ureteric strictures were counselled for ureteric reimplantation and consented to undergo surgery performed using the da Vinci SP surgical system. Demographics and peri-operative outcomes were collected after institutional review board approval (IRB 13-780). Patients provided informed consent having received an explanation for the adoption of the novel platform. The first patient was a woman referred to our institution for a left distal ureteric stricture after total hysterectomy for uterine fibroids with ureteric injury. The second patient was a man with BPH and recurrent UTIs, who was diagnosed with a 1.5-cm bladder stone and a large bladder diverticulum compressing the left distal ureter. The third patient was a man diagnosed with bilateral uretero-enteric anastomoses stricture status after radical cystectomy with orthotopic ileal neobladder urinary diversion for bladder cancer. RESULTS: The procedures were successfully completed. An extra port through a separate skin incision for the bedside assistant was placed for the first two procedures. In such cases, this additional port was used electively from the start of the procedure and did not represent a change in the treatment plan. Moreover, the port wound was used to accommodate the drainage. The bilateral ureteric reimplantation, however, was completed according to a pure single-site approach (no extra ports were placed out of the GelSeal cap). The mean operating times were 165, 150 and 180 min, respectively. Blood loss was 50 mL in all cases. No intra-operative complications occurred. Patients were discharged on postoperative days 1, 1 and 2, respectively, with normal serum creatinine levels. Neither transfusions nor major complications occurred. CONCLUSION: Robot-assisted reconstructive surgery for benign distal ureteric strictures is feasible and safe using the da Vinci SP surgical system.

Achieving tumour control when suspecting sinus fat involvement during robot-assisted partial nephrectomy: step-by-step.

OBJECTIVES: To report a single expert robotic surgeon's step-by-step surgical technique for achieving local cancer control during robot-assisted PN (RAPN) for T3 tumours. PATIENTS AND METHODS: Since January 2010 to December 2016, the institutional RAPN database was queried for patients who underwent transperitoneal RAPN performed by a single surgeon for tumours ≤4 mm from the collecting system at preoperative computed tomography (three points on the 'N [Nearness]' R.E.N.A.L. nephrometry-score item) that were pT3a involving sinus fat at final pathology. Baseline characteristics, perioperative and oncological outcomes (particularly positive surgical margins, PSMs), were identified. RESULTS: Of 1497 masses that underwent RAPN, 512 scored 3 points on the 'N' item of the R.E.N.A.L. nephrometry score assessment. In all, 24 patients had pT3a tumours involving sinus fat at final pathology and represented the analysed cohort. RAPN were performed according to the here described technique. No PSMs were reported. Trifecta achievement was 54.2%. Within a median follow-up of 30 months, two and one patients had recurrence or metastasis, respectively. Two patients died unrelated to renal cancer. Retrospective analysis and limited follow-up represent study limitations. CONCLUSION: In a selected cohort of patients with renal tumours near the sinus fat at baseline R.E.N.A.L. nephrometry score assessment and confirmed pT3a at final pathology, the described RAPN technique was able to achieve optimal local cancer control.

"At-risk" kidney: How surgical factors influence renal functional preservation after partial nephrectomy.

OBJECTIVES: To investigate the influence of surgical modifiable factors on chronic kidney disease upstaging in a contemporary cohort of patients with normal and "at-risk" kidneys undergoing partial nephrectomy. METHODS: We reviewed 778 consecutive patients with (n = 634)/without (n = 144) chronic kidney disease or risk factors for chronic kidney disease in our institutional partial nephrectomy database. Chronic kidney disease upstaging was assessed using glomerular filtration rate measurements preoperatively and at 3-12 months postoperatively. Using a multivariate logistic regression, baseline clinicodemographic factors, and the operative measurements of excisional volume loss and warm and cold ischemia time on rates of chronic kidney disease upstaging were determined. Marginal effects were used to analyze the impact of ischemia time and generate interaction curves. RESULTS: Chronic kidney disease/risk factors for chronic kidney disease had equivalent rates of chronic kidney disease upstaging as the healthy kidney cohort (31.5% vs 38.2%, P = 0.15). Of the entire cohort, 2.8% were upstaged to stage IV-V chronic kidney disease. Multivariate analysis found a significant association between chronic kidney disease upstaging and excisional volume loss in both cohorts (no chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.63, P = 0.04; chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.42, P = 0.001). Only in the chronic kidney disease/risk factors for chronic kidney disease cohort, there was an association between ischemia type/duration and chronic kidney disease upstaging (odds ratio 1.04, P = 0.04). Warm ischemia began to predict an increased risk of chronic kidney disease upstaging at 17.6 min, which became statistically significant at 49 min. CONCLUSIONS: Chronic kidney disease upstaging is common after partial nephrectomy. Although volume loss unequivocally affects rates of upstaging irrespective of baseline renal function, warm ischemia time disproportionately influences "at-risk" kidneys. Therefore, strong consideration should be given to minimizing volume loss and using cold ischemia when extended clamp times are anticipated in "at-risk" kidneys.

Single-Port Trans-Perineal Approach to Cystoprostatectomy with Intracorporeal Ileal Conduit Urinary Diversion and Lymph-Nodes Dissection using a Purpose-Built Robotic System: Surgical Steps in a Preclinical Model.

AIM: To report the technique for single-port trans-perineal cystoprostatectomy with intracorporeal ileal conduit urinary diversion and lymph nodes dissection using a purpose-built robotic platform (da Vinci SP1098, Intuitive Surgical, Sunnyvale, CA, USA). MATERIALS AND METHODS: In a male cadaver the SP1098 robotic system was used to perform cystoprostatectomy with intracorporeal ileal conduit urinary diversion and lymph nodes dissection by single-port trans-perineal approach. The surgery was completed through a 2.5-cm perineal incision through which a GelPOINT Mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) and a dedicated 25-mm multichannel port accommodating a 12 x 10-mm oval articulating robotic camera, three 6-mm double-jointed articulating robotic instruments and a 6-mm accessory laparoscopic instrument were positioned. At the planned level of the stoma for the ileal conduit, a 12-mm port was placed through which the EndoGIA® stapler was used to mature the urinary diversion Results: The total operative time was 185 min. The procedure was successfully completed without the need for additional ports placement. The benefits of the trans-perineal approach, particularly in longer procedures as radical cystectomy with intracorporeal urinary diversion, might include the avoided need of Trendelenburg position, with undoubtful advantages for the patient and the anesthesiologist in terms of respiratory mechanics and hemodynamics. CONCLUSIONS: The feasibility of single-port trans-perineal cystoprostatectomy with intracorporeal ileal conduit urinary diversion and lymph nodes dissection using the SP1098 purpose-built robotic platform is demonstrated. The duplication of the described surgical steps in the clinical model is awaited when the platform will be available on the market.

Robotic partial nephrectomy after pazopanib treatment in a solitary kidney with segmental vein thrombosis.

OBJECTIVE: To demonstrate our surgical technique of robotic partial nephrectomy (RPN) in a patient with a solitary kidney who received neoadjuvant Pazopanib, highlighting the multidisciplinary approach. MATERIALS AND METHODS: In our video, we present the case of 77-year-old male, Caucasian with 6.6cm left renal neoplasm in a solitary kidney. An initial percutaneous biopsy from the mass revealed clear cell RCC ISUP 2. After multidisciplinary tumor board meeting, Pazopanib (800mg once daily) was administered for 8 weeks with repeat imaging at completion of therapy. Post-TKI image study was compared with the pre-TKI CT using the Morphology, Attenuation, Size, and Structure criteria showing a favorable response to the treatment. Thereafter, a RPN was planned3. Perioperative surgical outcomes are presented. RESULTS: Operative time was 224 minutes with a cold ischemia time of 53 minutes. Estimated blood loss was 800ml and the length of hospital stay was 4 days. Pathology demonstrated a specimen of 7.6cm with a tumor size of 6.5cm consistent with clear cell renal carcinoma ISUP 3 with a TNM staging pT1b Nx. Postoperative GFR was maintained at 24 ml / min compared to the preoperative value of 33ml / min. CONCLUSIONS: A multidisciplinary approach is effective for patients in whom nephron preservation is critical, providing na opportunity to select those that may benefi t from TKI therapy. Pazopanib may allow for PN in a highly selective subgroup of patients who would otherwise require radical nephrectomy. Prospective data will be necessary before this strategy can be disseminated into clinical practice. Available at: http://www.intbrazjurol.com.br/video-section/20180240_Garisto_et_al.

Robot-assisted transvesical partial prostatectomy using a purpose-built single-port robotic system.

OBJECTIVES: To evaluate the feasibility of robot-assisted single-port (SP) transvesical partial prostatectomy (TVPP) using a novel purpose-built SP surgical platform in a pre-clinical model. METHODS: The cadavers were placed in the lithotomy position. A 3-cm midline incision was made in the suprapubic area 4-cm from the symphisis pubis. After opening the Retzius space, an access mini device (GelPOINT; Applied Medical, Rancho Margarita, CA, USA) was introduced percutaneously directly into the bladder. The da Vinci SP1098 robotic platform (Intuitive Surgical, Sunnyvale, CA, USA) was docked to the GelPOINT by inserting a novel SP cannula through the GelSeal Cap. The surgical steps for en bloc anterior prostatectomy were performed in the following order: (i) antegrade dissection of the transition zone at the bladder neck; (ii) lateral excision of the peripheral zone; and (iii) urethrovesical anastomosis. Primary outcomes, such as intra-operative complications, rate of conversion to standard techniques and operating times, were recorded. RESULTS: The SP-TVPP procedure was technically completed in three male cadavers. All cases were completed successfully using the da Vinci SP1098 surgical system without conversion or the need for additional ports. There were no intra-operative complications. The mean total operating time was 49.3 min. CONCLUSION: Robot-assisted TVPP is feasible using a novel purpose-built SP surgical platform in a cadaver model. Future clinical evaluation in humans is needed for assessment on patients with anterior localized prostate cancer. Prospective comparison with other surgical platforms and standard techniques is warranted.

Active Surveillance for Prostate Cancer: How to Do It Right.

Prostate cancer is the most common malignancy affecting men. There has been a nearly 70% increase in new prostate cancer cases, mostly classified as low risk, that have been diagnosed in early stages as a consequence of prostate-specific antigen (PSA) screening. Data regarding the natural history of this disease confirm the clinical insignificance of low-grade prostate cancer, which is associated with scant or no metastatic dissemination. Active surveillance is a conservative management approach, conducted for those patients with "low-risk" or "favorable-risk" disease, which avoids long-term adverse effects on the patient's quality of life. It is characterized by a routine protocol of close monitoring with digital rectal examination, periodic biopsy, and serial PSA testing. As defined by D'Amico, active surveillance is broadly appropriate for men with a Gleason score of 6 or less and a PSA level of less than 10 ng/mL. Typically, Gleason pattern 3 disease lacks the common genetic aberrancies of a true cancer. An essential element of the active surveillance approach is early recognition of higher-risk disease, which is diagnosed by systematic biopsy in 30% of patients who initiate active surveillance with low-risk disease. Also, a small group of patients have molecular alterations that can cause progression to more aggressive disease; these men can be switched to immediate treatment if such progression is detected. Oncologic outcomes for active surveillance cohorts have shown the long-term safety of this approach, with a cancer-specific mortality rate of 3% at 10 to 15 years. In this review of active surveillance for favorable-risk prostate cancer, we will discuss the rationality of this approach, the biological evidence for employing active surveillance in Gleason pattern 3 and 4 prostate cancer, patient selection for active surveillance, clinical trial data on active surveillance, and the role of prostate cancer biomarkers and imaging studies (MRI) for clinical decision making in patients with low-risk disease.

Protection from outpatient sudden cardiac death following ICD removal using a wearable cardioverter defibrillator.

BACKGROUND: An implantable cardioverter defibrillator (ICD) is effective in preventing sudden cardiac death (SCD). Once an ICD is removed and reimplantation is not feasible, a wearable cardioverter defibrillator (WCD) may be an alternative option. We determined the effectiveness of WCD for SCD prevention in patients who were discharged after ICD removal. METHODS: A retrospective study was conducted on all WCD (LifeVest, ZOLL, Pittsburgh, PA, USA) patients who underwent ICD removal due to cardiac device infections (CDIs) at two referral centers between January 1, 2005 and December 31, 2009. Clinical characteristics, device information, and WCD data were analyzed. Sudden cardiac arrest was defined as all sustained ventricular tachycardia (VT) and ventricular fibrillation occurring within a single 24-hour period. RESULTS: Ninety-seven patients (mean age 62.8 ± 13.3, male 80.4%) were included in the study. The median duration of antibiotic use was 14.7 days (interquartile range [IQR] 10-30). The median daily WCD use was 20 hours/day and the median length of use was 21 days (IQR 5-47). A total of three patients were shocked by WCD. Two patients had four episodes of sustained VT, successfully terminated by the WCD. A third patient experienced two inappropriate treatments due to oversensitivity of the signal artifact. Three patients experienced sudden death outside the hospital while not wearing the device. Five patients died while hospitalized. CONCLUSION: WCD can prevent SCD, until ICD reimplantation is feasible in patients who underwent device removals for CDI. However, patient compliance is essential for the effective use of this device.

Prevalence of chronic kidney disease in patients undergoing cardiac rhythm device removal.

Cardiac implantable electronic device (CIED) leads can cause central venous stenosis (CVS). In addition, these devices can get infected. Both are critically important considerations in patients with chronic kidney disease (CKD) for at least two reasons: (i) central veins serve as the final pathway should these patients need an arteriovenous access to provide dialysis therapy; and (ii) the presence of renal failure increases the risk of CIED infection. In this analysis, we investigated the prevalence as well as the degree of chronic kidney disease in patients harboring a CIED. Patients undergoing CIED removal were evaluated from 2001 to 2011. The patients were categorized into CKD stage I-V based on National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines. A total of 503 patients underwent CIED removal. Demographic characteristics revealed that 30% had hypertension, 44% were diabetics, 77% had coronary artery disease, and 84% suffered from congestive heart failure. Ninety percent (452/503) of the patients had CKD (stage I = I9 [4.2%], stage II = 189 [41.8%], stage III A = 96 [21.2%], stage III B = 59 [13.0%], stage IV = 45 [9.9%], and stage V = 44 [9.7%]). Overall, 148 (32.7%) patients (stage III B, stage IV, and stage V) of 452 had advanced renal failure. The results of this study reveal that one-third of CIED patients undergoing device removal have advanced chronic kidney disease.

Epicardial cardiac rhythm devices for dialysis patients: minimizing the risk of infection and preserving central veins.

Transvenous leads of cardiac rhythm devices (CRDs) are known to cause central stenosis and are vulnerable to contamination during hemodialysis access-related bacteremia. In this retrospective study, nine consecutive chronic hemodialysis patients with transvenous CRD infection due to dialysis access-related bacteremia and recurrent central stenosis are presented. Four patients with tunneled hemodialysis catheters (TDCs) and three with arteriovenous grafts experienced access-related bacteremia that spread to the transvenous CRD. Two patients required repeated angioplasty procedures (less than 3 months apart) for central venous stenosis. Transvenous CRD was removed and replaced with an epicardial system in all. One patient with TDC switched to peritoneal dialysis and did not experience infection of the epicardial system despite two episodes of peritonitis. The remaining TDC (n=3) and graft patients (n=3) received a new TDC after the resolution of bacteremia. While all six experienced on average 1.5 episodes of catheter-related bacteremia (average follow-up = 14.5 months), none developed infection of the epicardial system. The patients with central stenosis have required only one angioplasty each for the past 8 and 6 months. To the best of our knowledge this is the first study to suggest that an epicardial approach might be a preferred method over transvenous leads for chronic hemodialysis patients.

Robotic Off-Clamp Simple Enucleation Single-Layer Renorrhaphy Partial Nephrectomy (ROSS): Surgical Insights after an Initial Experience.

Robotic technology allows the beginner surgeon to approach minimally-invasive partial nephrectomy (PN) avoiding the otherwise long learning curve of pure laparoscopy. The present video-article reported the surgical technique and the outcomes of the first 11 cases performed by a young surgeon starting with the experience of robotic PN. Transperitoneal robotic PN, with an off-clamp approach, a simple enucleation technique, and a single-layer medullar renorrhaphy was performed uneventfully in all cases but one, with comparable outcomes to the available literature. With the present experience, we are trying to give the reader a different point of view of the current knowledge. In our series, off-clamp robotic PN was not chosen while looking for a better functional outcome, but rather as a "forced" choice within the specific "in training" setting the interventions were performed in. We underline how the off-clamp approach was the way to cut out the potential for vascular complications derived from the application/removal of the clamp itself on the renal artery. Indeed, when Scanlan bulldogs are not available, one of the limits of robotic PN is that the first surgeon is not autonomous in placing/removing the clamp. We found that tumour enucleation resection technique had the perfect synergistic effect in maximizing the perioperative vision, and thus the safety, notwithstanding the clampless approach.

On-Clamp vs. Off-Clamp Robot-Assisted Partial Nephrectomy for cT2 Renal Tumors: Retrospective Propensity-Score-Matched Multicenter Outcome Analysis.

We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13−4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27−0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.