External validation of yonsei nomogram predicting chronic kidney disease development after partial nephrectomy: An international, multicenter study.

OBJECTIVE: To externally validate Yonsei nomogram. METHODS: From 2000 through 2018, 3526 consecutive patients underwent on-clamp PN for cT1 renal masses at 23 centers were included. All patients had two kidneys, preoperative eGFR ≥60 ml/min/1.73 m2, and a minimum follow-up of 12 months. New-onset CKD was defined as upgrading from CKD stage I or II into CKD stage ≥III. We obtained the CKD-free progression probabilities at 1, 3, 5, and 10 years for all patients by applying the nomogram found at https://eservices.ksmc.med.sa/ckd/. Thereafter, external validation of Yonsei nomogram for estimating new-onset CKD stage ≥III was assessed by calibration and discrimination analysis. RESULTS AND LIMITATION: Median values of patients' age, tumor size, eGFR and follow-up period were 47 years (IQR: 47-62), 3.3 cm (IQR: 2.5-4.2), 90.5 ml/min/1.73 m2 (IQR: 82.8-98), and 47 months (IQR: 27-65), respectively. A total of 683 patients (19.4%) developed new-onset CKD. The 5-year CKD-free progression rate was 77.9%. Yonsei nomogram demonstrated an AUC of 0.69, 0.72, 0.77, and 0.78 for the prediction of CKD stage ≥III at 1, 3, 5, and 10 years, respectively. The calibration plots at 1, 3, 5, and 10 years showed that the model was well calibrated with calibration slope values of 0.77, 0.83, 0.76, and 0.75, respectively. Retrospective database collection is a limitation of our study. CONCLUSIONS: The largest external validation of Yonsei nomogram showed good calibration properties. The nomogram can provide an accurate estimate of the individual risk of CKD-free progression on long-term follow-up.

Mirabegron versus Solifenacin in Children with Overactive Bladder: Prospective Randomized Single-Blind Controlled Trial.

PURPOSE: The purpose of this study is to investigate the efficacy and safety of mirabegron versus solifenacin in the treatment of newly diagnosed overactive bladder (OAB) in children. METHODS: We conducted a prospective randomized controlled study on pediatric patients with newly diagnosed OAB. Patients were randomized into 3 groups: mirabegron (50 mg once daily) in group I, solifenacin (5 mg) in group II, and placebo in group III. Before starting our treatment and at the end of the 3 months course, we obtained a 3-day voiding diary. This diary included incontinence episode per day, mean voided volume per micturition, mean number of micturition per day, and post-void residual urine. Moreover, the parents/patients were asked to rate symptom relief, and the adverse events were recorded throughout the study period. RESULTS: A total of 190 patients aged from 5 to 14 years completed this study. At the end of this trial, both groups I and II showed significant improvement versus placebo regarding our efficacy parameters with no significant difference between group I and II. The overall success rate based on assessment of symptom relief was significantly higher in the treated groups (87.5% in I and 90.2% in II) versus placebo (55.8%). Dry mouth was reported in 2.8, 10, and 0% and constipation in 2.8, 11.4, and 1.4% in group I, II, and III, respectively, without statistically significant difference between group I and placebo. However, there was a significant difference between group II and placebo regarding these side effects. CONCLUSION: Both mirabegron and solifenacin have comparable efficacy regarding the control of OAB symptoms in the newly diagnosed children, but mirabegrone seems to have less side effects.

Silodosin versus Tamsulosin as Medical Expulsive Therapy for Children with Lower-Third Ureteric Stones: Prospective Randomized Placebo-Controlled Study.

AIM: To compare the efficacy and safety of silodosin versus tamsulosin as medical expulsive therapy for stones of lower-third ureter in children. PATIENTS AND METHODS: This prospective single-blind placebo-controlled randomized study included 167 pediatric patients who presented with distal ureteric stone (DUS) less than 1 cm. Patients were randomized into 3 groups; group I received silodosin 4 mg once daily, and group II received tamsulosin 0.4 mg while those in group III had placebo. The side effects of the used drugs, both rate and time of stone expulsion, and number of pain episodes were compared among the study groups for a maximum of 4 weeks. RESULTS: Follow-up data of our patients after treatment revealed that the stone expulsion rate was significantly higher and the time to stone expulsion was significantly shorter in group I (89.3%, 12.4 ± 2.3 days) and group II (74.5%, 16.2 ± 4.2 days) compared to group III (51.8%, 21.2 ± 5.6). However, a statistically significant difference between silodosin and tamsulosin groups in favor of the former one was reported regarding the 2 studied items. Meanwhile, pain episodes requiring analgesia were statistically fewer in group I and II in contrast to placebo group. Adverse events were comparable among all groups. CONCLUSION: Silodosin provides significantly better stone expulsion rate and shorter expulsion time than tamsulosin for treatment of DUS. Both medications showed good safety profiles in children. However, further studies are required on a larger scale to confirm our results. Assessment of drug safety on younger age-group is still needed.

Partial versus radical nephrectomy in very elderly patients: a propensity score analysis of surgical, functional and oncologic outcomes (RESURGE project).

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.

Retzius-sparing robot-assisted radical prostatectomy using the Revo-i robotic surgical system: surgical technique and results of the first human trial.

OBJECTIVE: To evaluate the safety and proficiency of the Revo-i® robotic platform (Meere Company Inc.) in the treatment of prostate cancer (PCa). PATIENTS AND METHODS: A prospective study was carried out on 17 patients with clinically localized PCa treated between 17 August 2016 and 23 February 2017 at our urology department using the Revo-i. Patients underwent Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). The primary objective was to describe the RS-RARP step-by-step surgical technique using the Revo-i. In addition, the safety of the Revo-i was assessed according to intra-operative and the postoperative complications within 30 days of surgery. Early oncological outcomes were also assessed according to surgical margin status and biochemical recurrence (BCR). Continence was defined as use of no or only one pad. Surgeons' satisfaction with the Revo-i was assessed using the Likert scale. RESULTS: All surgeries were completed successfully, with no conversion to open or laparoscopic surgery. The median patient age was 72 years. The median docking time, console time, urethrovesical anastomosis time and estimated blood loss were 8 min, 92 min, 26 min and 200 mL, respectively. One patient was transfused intra-operatively as a result of blood loss of 1 500 mL. Postoperatively, two patients received blood transfusion, and there were no other serious/major complications. The median hospital stay was 4 days. At 3 months, four patients had positive surgical margins, one patient had BCR, and 15 patients were continent. Most of surgeons were satisfied with the Revo-i performance. CONCLUSIONS: The first human study for the treatment of patients with localized PCa using the Revo-i robotic surgical system was carried out successfully. The peri-operative, early oncological and continence outcomes are encouraging. Further prospective studies are warranted to support our preliminary results.

Functional and oncological outcomes of open, laparoscopic and robot-assisted partial nephrectomy: a multicentre comparative matched-pair analyses with a median of 5 years' follow-up.

OBJECTIVES: To compare outcomes at a 5-year median follow-up among different partial nephrectomy (PN) approaches: robot-assisted (RAPN), laparoscopic (LPN) and open partial nephrectomy (OPN). PATIENTS AND METHODS: We retrospectively analysed 1 308 patients who underwent PN (RAPN, n = 380; LPN, n = 206; OPN, n = 722) between 2006 and 2012 at one of four academic centres. We performed 1:1:1 propensity-score-matching adjustment based on confounding variables among groups, and 366 patients (122 in each group) were included in the final analysis. Survival rates were analysed using the Kaplan-Meier method. RESULTS: The median follow-up periods were 60, 59.8 and 64.1 months for RAPN, LPN and OPN, respectively. In the matched groups, RAPN resulted in significantly lower mean estimated blood loss compared with LPN (P = 0.025) and OPN (P = 0.040), while LPN was associated with a longer mean operating time compared with RAPN (P = 0.001) and OPN (P = 0.001). The hospital stay was shorter in the RAPN group (P = 0.008). Regarding the oncological outcomes, there were no significant differences among the three groups in local recurrence rate (P = 0.882), distant metastasis rate (P = 0.816) or deaths from cancer (P = 0.779). At latest follow-up, the incidence of chronic kidney disease (CKD) upstaging was significantly lower in RAPN compared with LPN (20.55% vs 32%; P = 0.035) and OPN (20.5% vs 33.6%; P = 0.038). The 5-year CKD free-survival rate was significantly higher (78.4%) in the RAPN group compared with 58.8% and 65.8% in the LPN and OPN groups, respectively (log-rank P = 0.031). CONCLUSIONS: In the present study, RAPN, LPN and OPN had similar local recurrence, distant metastasis and cancer-related death rates at a 5-year median follow-up. In terms of functional outcomes, RAPN was associated with a lower incidence of CKD upstaging compared with OPN and LPN.

Estimated glomerular filtration rate's time to nadir after robot-assisted partial nephrectomy: Predictors and clinical significance on renal functional recovery.

OBJECTIVES: To investigate the impact of postoperative time to nadir of estimated glomerular filtration rate on renal functional changes after robot-assisted partial nephrectomy. METHODS: From 2006 to 2015, 287 patients with renal mass who underwent robot-assisted partial nephrectomy in a referral center were analyzed. The cohort was evaluated based on their time to develop nadir: group 1 (no nadir), group 2 (<48 h) and group 3 (≥48 h). The outcome measures were to evaluate the renal function recovery between groups, risk factors for development of nadir ≥48 h, as well as predictors of chronic kidney disease upstaging. RESULTS: The mean estimated glomerular filtration rate percentage change was the worst in group 3 compared with groups 1 and 2, with 13.8%, -0.67% and 8%, respectively (P < 0.001). Chronic kidney disease upstaging was more common in group 3 compared with the other groups (P < 0.001). Age, tumor size, PADUA score and warm ischemia time were predictors of developing ≥48 h estimated glomerular filtration rate nadir (odds ratio 1.04, P = 0.002; odds ratio 1.43, P < 0.001; odds ratio 1.24, P = 0.018; odds ratio 1.05, P < 0.001), respectively. The 5-year probability of freedom from chronic kidney disease upstaging was lower in group 3 (75.6%) compared with the other groups - 88.1% and 100% (P = 0.003). Time to nadir ≥48 h was a predictor of chronic kidney disease upstaging (odds ratio 3.02, P = 0.022). CONCLUSIONS: A continuous decline in estimated glomerular filtration rate (≥48 h) after partial nephrectomy is associated with increased risk of poor functional recovery overtime. Age, tumor size, PADUA score and warm ischemia time are independent predictors of developing ≥48 h time to nadir of estimated glomerular filtration rate. This higher risk subgroup should be targeted for stricter follow up to allow early detection of future risk of renal functional decline.

Predictors of biochemical recurrence after Retzius-sparing robot-assisted radical prostatectomy: Analysis of 359 cases with a median follow-up period of 26 months.

OBJECTIVES: Our aim was to evaluate the predictors of biochemical recurrence after Retzius-sparing robot-assisted radical prostatectomy. METHODS: The study cohort consisted of 359 consecutive non-metastatic prostate cancer patients who underwent Retzius-sparing robot-assisted radical prostatectomy between November 2012 and January 2016. According to the National Comprehensive Cancer Network prostate cancer risk classification, 164 patients (45.7%) had high- or very high-risk prostate cancer. No patient received adjuvant therapy until documented biochemical recurrence. Biochemical recurrence-free survival was estimated using the Kaplan-Meier method. Univariable and multivariable Cox proportional hazards regression models were used to determine variables predictive of biochemical recurrence. RESULTS: The median follow-up period was 26 months (interquartile range 19-38 months). The overall biochemical recurrence rate was 14.8%, and the median time to biochemical recurrence was 11 months (interquartile range 6-22 months). The 3-year biochemical recurrence-free survival probability was 71.2%, 72.1%, 88.7%, 82.3% and 95.7% in very high-, high-, intermediate-, low- and very low-risk prostate cancer, respectively (log-rank, P < 0.001). On multivariable analysis, preoperative prostate-specific antigen (hazard ratio 1.03, 95% confidence interval 1.02-1.04; P < 0.0001), percentage of maximum core involvement on biopsy (hazard ratio 1.02, 95% confidence interval 1.01-1.03; P = 0.029) and clinical stage ≥T3a (hazard ratio 2.12, 95% confidence interval 1.02-4.39; P = 0.043) were predictors of biochemical recurrence, whereas pathological Gleason score ≥8 (hazard ratio 5.63, 95% confidence interval 1.62-19.61; P = 0.007) and pathological tumor volume (hazard ratio 1.08, 95% confidence interval 1.04-1.20; P < 0.001) were the main pathological predictors of biochemical recurrence. CONCLUSIONS: Retzius-sparing robot-assisted radical prostatectomy confers effective biochemical recurrence control at the mid-term follow-up period. Preoperative prostate-specific antigen, advanced clinical stage and higher Gleason score were important predictors of biochemical recurrence after Retzius-sparing robot-assisted radical prostatectomy. Long-term oncological safety still needs to be established.

Yonsei nomogram: A predictive model of new-onset chronic kidney disease after on-clamp partial nephrectomy in patients with T1 renal tumors.

OBJECTIVES: To develop a predictive nomogram for chronic kidney disease-free survival probability in the long term after partial nephrectomy. METHODS: A retrospective analysis was carried out of 698 patients with T1 renal tumors undergoing partial nephrectomy at a tertiary academic institution. A multivariable Cox regression analysis was carried out based on parameters proven to have an impact on postoperative renal function. Patients with incomplete data, <12 months follow up and preoperative chronic kidney disease stage III or greater were excluded. The study end-points were to identify independent risk factors for new-onset chronic kidney disease development, as well as to construct a predictive model for chronic kidney disease-free survival probability after partial nephrectomy. RESULTS: The median age was 52 years, median tumor size was 2.5 cm and mean warm ischemia time was 28 min. A total of 91 patients (13.1%) developed new-onset chronic kidney disease at a median follow up of 60 months. The chronic kidney disease-free survival rates at 1, 3, 5 and 10 year were 97.1%, 94.4%, 85.3% and 70.6%, respectively. On multivariable Cox regression analysis, age (1.041, P = 0.001), male sex (hazard ratio 1.653, P < 0.001), diabetes mellitus (hazard ratio 1.921, P = 0.046), tumor size (hazard ratio 1.331, P < 0.001) and preoperative estimated glomerular filtration rate (hazard ratio 0.937, P < 0.001) were independent predictors for new-onset chronic kidney disease. The C-index for chronic kidney disease-free survival was 0.853 (95% confidence interval 0.815-0.895). CONCLUSION: We developed a novel nomogram for predicting the 5-year chronic kidney disease-free survival probability after on-clamp partial nephrectomy. This model might have an important role in partial nephrectomy decision-making and follow-up plan after surgery. External validation of our nomogram in a larger cohort of patients should be considered.

Novel robotic systems and future directions.

Robot-assistance is increasingly used in surgical practice. We performed a nonsystematic literature review using PubMed/MEDLINE and Google for robotic surgical systems and compiled information on their current status. We also used this information to predict future about the direction of robotic systems based on various robotic systems currently being developed. Currently, various modifications are being made in the consoles, robotic arms, cameras, handles and instruments, and other specific functions (haptic feedback and eye tracking) that make up the robotic surgery system. In addition, research for automated surgery is actively being carried out. The development of future robots will be directed to decrease the number of incisions and improve precision. With the advent of artificial intelligence, a more practical form of robotic surgery system can be introduced and will ultimately lead to the development of automated robotic surgery system.

Perioperative and short-term outcomes of Retzius-sparing robot-assisted laparoscopic radical prostatectomy stratified by gland size.

OBJECTIVE: To investigate the effect of preoperative prostate volume (PV) on the perioperative, continence and early oncological outcomes among patients treated with Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RS-RALP). PATIENTS AND METHODS: This is a retrospective analysis of 294 patients with organ-confined prostate cancer treated with RS-RALP in a high-volume centre from November 2012 to February 2015. Patients were divided into three groups based on their transrectal ultrasonography estimated PV as follows: group 1, <40 mL (231 patients); group 2, 40-60 mL (47); group 3, >60 mL (16). Perioperative, oncological, and continence outcomes were compared between the three groups. RESULTS: The median [interquartile range (IQR)] PV for each group was; 26.1 (22-31) mL, 45.9 (41-50) mL, and 70 (68-85) mL. Blood loss was higher in group 3 compared to groups 2 and 1; at a median (IQR) of 475 (312-575) mL, 200 (150-400) mL, and 250 (150-400) mL, respectively (P = 0.001). The intraoperative transfusion rate was higher in group 3 patients (P = 0.004), while the complication rate did not differ (P = 0.05). The console time was slightly higher but was not statistically significant in group 3 compared to groups 2 and 1; at a mean (sd) of 100 (35) min, 92 (34.4) min, and 93 (24.8) min, respectively (P = 0.70). Biochemical recurrence and the continence rate did not differ between the three groups (P = 0.89 and P = 0.25, respectively). CONCLUSION: RS-RALP is oncologically and functionally equivalent for all prostate sizes but technically demanding for larger prostates. We therefore recommend that surgeons initiate their RS-RALP technique with smaller prostates.

Impact of preoperative calculation of nephron volume loss on future of partial nephrectomy techniques; planning a strategic roadmap for improving functional preservation and securing oncological safety.

OBJECTIVES: To assess the correlation of the resected and ischaemic volume (RAIV), which is a preoperatively calculated volume of nephron loss, with the amount of postoperative renal function (PRF) decline after minimally invasive partial nephrectomy (PN) in a multi-institutional dataset. PATIENTS AND METHODS: We identified 348 patients from March 2005 to December 2013 at six institutions. Data on all cases of laparoscopic (n = 85) and robot-assisted PN (n = 263) performed were retrospectively gathered. Univariable and multivariable linear regression analyses were used to identify the associations between various time points of PRF and the RAIV, as a continuous variable. RESULTS: The mean (sd) RAIV was 24.2 (29.2) cm3 . The mean preoperative estimated glomerular filtration rate (eGFR) and the eGFRs at postoperative day 1, 6 and 36 months after PN were 91.0 and 76.8, 80.2 and 87.7 mL/min/1.73 m2 , respectively. In multivariable linear regression analysis, the amount of decline in PRF at follow-up was significantly correlated with the RAIV (ß 0.261, 0.165, 0.260 at postoperative day 1, 6 and 36 months after PN, respectively). This study has the limitation of its retrospective nature. CONCLUSION: Preoperatively calculated RAIV significantly correlates with the amount of decline in PRF during long-term follow-up. The RAIV could lead our research to the level of prediction of the amount of PRF decline after PN and thus would be appropriate for assessing the technical advantages of emerging techniques.

Feasibility of Robot - assisted Segmental Ureterectomy and Ureteroureterostomy in Patient with High Medical Comorbidity.

INTRODUCTION AND OBJECTIVES: Nephroureterectomy remains the gold standard treatment option for upper tract tumors. However, segmental ureterectomy may be another option in patients with single kidney, borderline renal function or high medical comorbidities. The aim of this video is to assess the feasibility of robotic surgery as a minimally invasive technique in treatment of a high comorbid patient with ureteric tumor. MATERIALS AND METHODS: Eighty-year old male patient, with a medical history of chronic hypertensive and uncontrolled Diabetes Mellitus, was referred to our department for treatment of ureteric tumor. Patient underwent robot-assisted radical prostatectomy 5 years ago. Patient's Charlson comorbidity index score was 9. Computed tomography showed a 2.5cm right ureteral luminal filling enhancing lesion at lower part of upper 1/3 ureter. We performed diagnostic flexible cystoscopy under local anesthesia to exclude associated lower urinary tract carcinoma, and bladder wash was negative for malignancy. Under general anesthesia patient underwent diagnostic flexible ureteroscopy to confirm mass location, and a retrograde pyelography to rule out additional tumors on the right collecting system. Then, the patient was placed in the full lateral flank position without Table flexion. Ports placement were inserted as follow: a "12mm" optical trocar at pararectal line superior and lateral to umbilicus, two "8mm" robotic trocars cranial and caudal to optical trocar (8cm distance), a "8mm" robotic trocar towards anterior superior ischial spine, and a "12mm" assistant trocar was inserted between umbilicus and pubic bone. The surgical steps are shown in the video. RESULTS: The procedure was performed easily. The total operative time and consol time were 100 and 60 minutes, respectively. Blood loss was 50ml. No reported intraoperative or postoperative complications. Notably, we took full precautions in case of intraoperative failure to complete the procedure successfully, nephroureterectomy was our second option. Postoperative serum creatinine was 1.2mg/dL and length of hospital stay was 2 days. The frozen biopsy showed that the tumor was resected with safe proximal and distal surgical margins. Final histopathology revealed high grade (G3) urothelial carcinoma (pT3), measures (1.3x1.2x0.2cm), associated with carcinoma in situ. CONCLUSION: We affirm that robotic segmental ureterectomy and ureteroureterostomy could be offered safely as a minimally invasive treatment for patients with ureteric tumors and high-risk medical comorbidities. It provides excellent perioperative outcomes and early oncological safety with regard to surgical margins.

Robot-assisted Fallopian tube transection and anastomosis using the new REVO-I robotic surgical system: feasibility in a chronic porcine model.

OBJECTIVES: To evaluate the feasibility and safety of the new REVO-I robotic platform by performing Fallopian tube transection and anastomosis in live porcine models. SUBJECTS AND METHODS: A prospective chronic animal study was carried out in four crossbred female pigs. The primary outcome was assessment of the pigs' 2-week survival. The secondary outcomes were measurements of intra-operative variables and the complications or difficulties arising when using the REVO-I. RESULTS: Fallopian tube anastomosis was successfully performed in four porcine models. The mean (range) operating time was 66 (46-104 min), docking time 22.25 (14-53) min and console time 18 (13-20) min. The REVO-I robotic system functioned appropriately, with no technical problems or difficulties noted during the procedures. Both the surgeon and the bedside assistants reported ease of use and better performance with subsequent procedures. All pigs were alive 2 weeks after surgery, with no peri-operative complications related to the use of the robot. CONCLUSIONS: This preclinical chronic porcine study showed that the REVO-I robotic surgical system is a feasible and safe robotic instrument that can be used by surgeons to perform skillful robotic procedures in porcine models. Our next objective will be to demonstrate its safety in humans.

Outcomes of high-complexity renal tumours with a Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score of ≥10 after robot-assisted partial nephrectomy with a median 46.5-month follow-up: a tertiary centre experience.

OBJECTIVES: To compare perioperative trifecta achievement and long-term oncological and functional outcomes between patients with renal tumours of low [Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score 6-7], intermediate (PADUA score 8-9) and high (PADUA score ≥10) complexity undergoing robot-assisted partial nephrectomy (RAPN), and to determine predictors for trifecta achievement. PATIENTS AND METHODS: Data were retrospectively analysed from 295 patients, who underwent RAPN, between 2006 and 2015, at a high-volume tertiary centre. Trifecta achievement was the primary outcome measurement. The perioperative parameters and long-term oncological and functional outcomes were the secondary outcome measures. Groups were compared using the Kruskal-Wallis H test or chi-square test. Univariable and multivariable binary logistic regression analyses were used to determine the most important determinant variables associated with trifecta accomplishment. The Kaplan-Meier method was used to estimate overall survival (OS), cancer-specific survival (CSS) and cancer-free survival (CFS). RESULTS: Of the 295 patients, 121 (41%) had a PADUA score of ≥10. Patients in the high-complexity PADUA group had larger tumours (P ≤ 0.001), higher clinical stages ≥T1b (P < 0.001), an increased risk of malignancy (P = 0.02), longer warm ischaemia time (P = 0.0030), and higher estimated blood loss (P = 0.001) compared with those in the intermediate- and low-complexity groups. Seven of eight patients who were converted to radical nephrectomy had high-complexity tumours (P = 0.02). Trifecta achievement was less in the high-complexity PADUA group (P < 0.001). Renal functional outcomes did not differ among the groups at follow-up (P > 0.05). There were no significant differences between the groups for OS (P = 0.314), CSS (P = 0.228) and CFS (P = 0.532). In multivariable analysis, the American Society of Anesthesiologists classification, operative time and tumour size were independent predictors of trifecta achievement (P = 0.001, P = 0.03, and P = 0.006, respectively). CONCLUSION: High-complexity PADUA tumours are associated with a lower rate of trifecta achievement; however, long-term oncological and functional outcomes seem to be equivalent among high-, intermediate-, and low-complexity tumours. Despite the perioperative outcomes; high-complexity tumours can be handled successfully via the robotic approach and the improved long-term oncological and functional outcomes might be considered useful for patients counselling.

Robot-assisted partial nephrectomy confers excellent long-term outcomes for the treatment of complex cystic renal tumors: Median follow up of 58 months.

OBJECTIVES: To analyze long-term outcomes of robot-assisted partial nephrectomy for treatment of complex cystic renal tumors. METHODS: We retrospectively analyzed the data of patients who underwent robot-assisted partial nephrectomy for cystic (n = 32) and solid (n = 263) renal masses at Severance Hospital, Seoul, Korea. The primary outcome was assessment of perioperative safety for cystic tumor. Secondary outcomes were evaluation of long-term oncological and functional results. RESULTS: Patients' clinical and demographic characteristics were similar among both groups. The median follow up of cystic and solid masses were 58 and 46 months, respectively. Cystic masses were more likely to have low Fuhrman grade 1 and 2 (P = 0.03), and shorter operative time (P = 0.04) compared with solid masses. There was no statistically significant difference regarding warm ischemia time, estimated blood loss, trifecta achievement, length of hospital stay, complication rates and renal function preservation (P > 0.05) between groups. In the solid group, 12 patients (4.1%) recurred, and six patients (2%) died from metastatic renal cell carcinoma, whereas the patients in the cystic group did not have any local or distance recurrence, and the survival rates were 100%. The 5-year cancer-free survival (P = 0.77), cancer-specific survival (P = 0.65) and overall survival (P = 0.83) rates were similar between the groups. CONCLUSION: Robot-assisted partial nephrectomy appears to be safe and feasible treatment for complex cystic renal masses. It confers excellent long-term oncological outcomes. Robot-assisted partial nephrectomy should be the treatment of choice for complex cysts whenever feasible.

Stratified analysis of 800 Asian patients after robot-assisted radical prostatectomy with a median 64 months of follow up.

OBJECTIVE: To report the 5-year oncological outcomes of robot-assisted radical prostatectomy from the largest series ever reported from Asia. METHODS: A retrospective analysis of 800 Asian patients who were treated with robot-assisted radical prostatectomy from July 2005 to May 2010 in the Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea was carried out. The primary end-point was to evaluate the biochemical recurrence. The secondary end-point was to show the biochemical recurrence-free survival, metastasis-free survival and cancer-specific survival. RESULTS: A total of 197 (24.65%), 218 (27.3%), and 385 (48.1%) patients were classified as low-, intermediate- and high-risk patients according to the D'Amico risk stratification risk criteria, respectively. The median follow-up period was 64 months (interquartile range 28-71 months). The overall incidence of positive surgical margin was 36.6%. There was biochemical recurrence in 183 patients (22.9%), 38 patients (4.8%) developed distant metastasis and 24 patients (3%) died from prostate cancer. Actuarial biochemical recurrence-free survival, metastasis-free survival, and cancer-specific survival rates at 5 years were 76.4%, 94.6% and 96.7%, respectively. Positive lymph node was associated with lower 5-year biochemical recurrence-free survival (9.1%), cancer-specific survival (75.7%) and metastasis-free survival (61.9%) rates (P < 0.001). On multivariable analysis, among all the predictors, positive lymph node was the strongest predictor of biochemical recurrence, cancer-specific survival and metastasis-free survival (P < 0.001). CONCLUSIONS: Herein we report the largest robot-assisted radical prostatectomy series from Asia. Robot-assisted radical prostatectomy is confirmed to be an oncologically safe procedure that is able to provide effective 5-year cancer control, even in patients with high-risk disease.

Clinical significance of prostatic-urethral angulation on the treatment outcome of patients with symptomatic benign prostatic hyperplasia treated with tamsulosin hydrochloride.

OBJECTIVES: To evaluate the impact of the prostatic-urethral angulation (PUA) on the treatment efficacy of selective alpha-1A receptor blocker in male patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH). MATERIALS AND METHODS: A total of 80 patients with LUTS/BPH and with mean age 53.3 ± 6.3 (range 47-70) were included in our prospective comparative study. The patients were classified into 2 groups as a consecutive cases 40 in each one depending on the PUA either ≤ 35° (group A) or > 35° (group B). PUA and different prostatic parameters were measured using transrectal ultrasound. Prostate-specific antigen (PSA), the International Prostate Symptom Score and quality of life score (IPSS/QoL score), maximum flow rate (Qmax), and postvoid residual (PVR) volume were compared between the groups. The clinical significance of PUA was evaluated after 8 weeks of medical treatment with tamsulosin hydrochloride 0.4 mg daily. RESULTS: Baseline evaluation (pre-treatment) for both groups were comparable to each other with no clinically significant difference regarding age, PSA, IPSS/QoL score, Q(max) and PVR volume (P-value > 0.05). Comparison of parameters after 8 weeks showed that tamsulosin hydrochloride improved the total IPSS and all subscores (P < 0.001), QoL (P = 0.001), Q(max) (P = 0.002), and PVR (P = 0.04) in group A (Table 1). CONCLUSION: Tamsulosin hydrochloride appears to be less effective in improving IPSS/Qol score, Qmax and PVR in patients with lager PUA. The PUA might be a predictor for the treatment efficacy of α-blockers and more studies are warranted in the future before the final conclusion.