Metastatic prostatic adenocarcinoma presenting as generalized lymphadenopathy unmasked by a COVID booster vaccine.

Key Clinical Message: Lymphadenopathy following recent immunization is usually regional. Generalized lymphadenopathy should arouse suspicion for alternative underlying pathology. Prostate adenocarcinoma should be considered in the differential diagnosis for malignancy in an elderly male patient. Metastatic prostate adenocarcinoma can have good prognostic outcomes if treatment is started promptly, even in the setting of widespread disease. Abstract: Generalized lymphadenopathy is commonly attributed to infectious causes or malignancy, often lymphoproliferative disorders. We present a rare case of metastatic prostate cancer diagnosed after initially presenting as generalized lymphadenopathy following a coronavirus disease 2019 (COVID) booster vaccination. A 70-year-old Hispanic male presented with left lower quadrant abdominal pain, nausea, headache, myalgia, severe constipation, and a right-sided neck swelling that had been increasing in size since the day of his vaccination. Computed tomography (CT) scans of soft tissue neck, chest, abdomen, and pelvis with contrast showed extensive lymphadenopathy. Ultrasound-guided biopsy results of the enlarged right supraclavicular node and prostate revealed histopathology consistent with that of prostate acinar adenocarcinoma. He started on bicalutamide for 4 weeks, transitioned to gonadotropin releasing hormone analogue (leuprolide) injections every 3 months and oral androgen receptor signaling inhibitor (abiraterone with prednisone daily). PSA level declined from 121 ng/mL at diagnosis to 1.3 ng/mL after 3 months of therapy, and repeat imaging showed marked improvement in the size of his mediastinal, retroperitoneal, and pelvic lymphadenopathy. To the best of our knowledge, this is the first case reported of a COVID vaccine booster uncovering lymphadenopathy leading to the diagnosis of metastatic prostate cancer.

Urothelial carcinoma with mandibular metastasis and synchronous prostate cancer.

Only 4% of newly diagnosed bladder cancer (BC) patients present with metastatic disease. The most common reported sites of metastases are lymph nodes, bones, lung, liver and peritoneum. Mandibular metastasis is very rare. We report a case of muscle-invasive urothelial cancer metastasised to the mandible and with an incidental finding of high-risk prostate cancer (PC). Incidental finding of PC in BC patients may be suggestive of a common aetiology. Treatment for BC and PC can be delivered in parallel, including platinum-based chemotherapy, cystectomy and androgen depletion therapy. Prognosis of metastatic BC is poor, and high-risk PC may affect progression-free survival of BC. Our case highlights importance of considering BC metastasis to the jaw as well as synchronous PC in the management of patients presenting with BC.

Replicated Risk Index of Patient Functional Status Prior to Allogeneic Hematopoietic Cell Transplantation Predicts Healthcare Utilization and Survival.

Poor physical functioning is associated with adverse outcomes after allogeneic hematopoietic cell transplantation (alloHCT). Analytic tools to predict mortality in alloHCT recipients include the HCT Comorbidity Index (HCT-CI) based on comorbidities and the Disease Risk Index (DRI) based on disease and disease status. We developed and replicated a risk model for overall survival (OS), early mortality (ie, death from any cause at or before day +100), initial hospital length of stay (LOS), and percentage of inpatient days within the first year post-alloHCT. In this study, we incorporated a physical therapy (PT) assessment with the HCT-CI and DRI to improve outcome predictions. The well-defined and feasible measure of functional status for assessing risk includes (1) the number of sit-to-stands performed in 30 seconds, (2) performance of 25 step-ups on the right/left side with (3) oxygen saturation recovery and (4) heart rate recovery, (5) weight-bearing ability, (6) assistance with ambulation, (7) motor and grip strength, (8) sensory and coordination impairment (eg, self-reported peripheral neuropathy, imbalance), (9) self-reported pain, and (10) limited endurance (ie, inability to complete step-ups and/or sit-to-stands). Our training cohort (TC) included 349 consecutive alloHCT recipients at Roswell Park treated between 2010 and 2016 and a subsequent replication cohort (RC; n = 163) treated between 2016 and 2019. Four of the 10 metrics-self-reported pain, limited endurance, self-reported neuropathy, and <10 sit-to-stands in 30 seconds-were identified as significant predictors and were included in the multivariable models with the HCT-CI and DRI to create a new risk index (HCT-PCDRI: HCT-physical, comorbidity, and DRI) for outcomes. Models were tested in the RC. Shorter OS was associated with self-reported pain, limited endurance, higher HCT-CI, and higher DRI. At a median follow-up of 34 months, the 3-year OS based on the HCT-PCDRI was 30% for the very-high-risk group, 54% for the high-risk group, 49% for the intermediate-risk group, and 80% for the low-risk group. The number of patients identified as very high risk increased from 55 using HCT-CI alone to 120 with the new HCT-PCDRI, whereas the number in the low-risk group decreased from 91 to 45. Early mortality and a higher percentage of inpatient days within the first year post-alloHCT (a proxy for poor quality of life and high healthcare utilization) were associated with self-reported pain, higher HCT-CI, and higher DRI. A shorter initial LOS (ie, initial low healthcare utilization) was associated with performance of >10 sit-to-stands in 30 seconds, no self-reported neuropathy, and lower HCT-CI. These PT metrics combined with the HCT-CI and DRI created the HCT-PCDRI, which resulted in more patients being categorized accurately as high risk versus low risk. The HCT-PCDRI results were replicated in an independent cohort. Pre-alloHCT PT metrics with self-reported symptoms (pain and neuropathy) were associated with survival post-alloHCT and prolonged hospital LOS. The HCT-PCDRI scoring system for risk stratification of alloHCT recipients more accurately identifies patients at potential risk of poor outcomes. The HCT-PCDRI can be tested in <15 minutes to identify patients for intervention before or during treatment to potentially improve outcomes.

Relative Risk of Peripheral Neuropathy With Ado-Trastuzumab Emtansine (T-DM1) Compared to Taxane-Based Regimens in Human Epidermal Growth Factor Receptor 2 (HER2)-Positive Cancers: A Systematic Review and Meta-Analysis.

Background Peripheral neuropathy (PN), especially peripheral sensory neuropathy (PSN), is significant toxicity of taxanes, the most used class of microtubule inhibitors for human epidermal growth factor receptor 2 (HER2)-positive breast cancer patients. Ado-trastuzumab emtansine (T-DM1) is a HER2-targeted antibody-drug conjugate, consisting of trastuzumab and a microtubule inhibitor DM1, which has been approved for HER2-positive breast cancer. T-DM1 has also been found to cause significant PN, including PSN. Methods We conducted a systematic review and meta-analysis of phase 3 randomized controlled trials using T-DM1 in the experimental arm and a taxane-based regimen in the control arm to determine the relative risk of PN and PSN associated with T-DM1 as compared to taxanes. A total of 1,857 patients were included in the analysis. The Cochran-Mantel-Haenszel method and the random-effects model were used to calculate the pooled risk ratio (RR) with a 95% confidence interval (CI) for all-grade and grade ≥3 PN and PSN.  Results The relative risks of all-grade PN and all-grade PSN were lower with T-DM1 compared to taxanes. The pooled RR of all-grade PN was 0.59, 95% CI: 0.39-0.89, P = 0.01, and the pooled RR of all-grade PSN was 0.58, 95% CI: 0.46-0.74, P < 0.0001. Conclusions Our meta-analysis demonstrated that T-DM1 is associated with a relatively lower risk of all-grade PN and PSN than the taxane-based regimens for HER2-positive cancers. It could be an area of consideration in selecting therapy for HER2-positive breast cancer patients at high risk of developing or having pre-existing PN and PSN.

Docetaxel-induced acute myositis: a case report with review of literature.

Docetaxel is an anti-microtubule agent and a highly effective treatment of locally advanced and metastatic breast cancer. There are several adverse effects associated with docetaxel, such as myelosuppression, peripheral neuropathy, fluid retention, and asthenia. One of the most well-known side-effects of this medication is mild to moderate myalgia. Here, we report a case of a 49-year-old female with stage 3 breast cancers who developed severe acute myositis following docetaxel use. The mechanism of docetaxel-induced myositis remains unclear; however, physicians still need to be aware of the possibility of this complication in patients with cancer and a history of exposure to this medication.

Oncologic manifestations of Klinefelter syndrome.

Klinefelter syndrome (47,XXY) has a prevalence of approximately 1 in 500 males. It is a condition characterized by an extra X chromosome and is an underdiagnosed clinical entity. Inactivation of genes enables their escape from regulatory mechanisms, which can result in such classic physical manifestations as hypogonadism, gynecomastia, infertility, and various hormonal and physical abnormalities. While the endocrine manifestations of 47,XXY are well-known, the oncologic manifestations have received less attention. An association between cancer and 47,XXY has not as yet been clearly defined, with variability noted in the prevalence of different malignancies in 47,XXY patients. The mechanisms underlying these altered oncologic risks are still under debate. Some of the proposed explanations include hormone imbalance, developmental malfunctions, and failed DNA repair mechanisms. However, the recognition of the oncological associations linked to 47,XXY could be helpful. Screening measures in certain malignancies may enable an earlier diagnosis of 47,XXY and the implementation of more customized care in 47,XXY and the mosaic variants.. The data for this review was compiled from relevant PubMed articles published within the last three decades and organized based on cancer type.

Non-osseous soft tissue metastasis in the foot from renal cell carcinoma.

Metastatic tumours of the distal extremities, also known as acrometastases, are rare. The majority of the acrometastases involve bones-involvement of the soft tissues of the feet and hands is extremely rare. We report a case of clear cell renal cell carcinoma metastasised to the soft tissues of the foot. The patient presented with pain and swelling in his right foot. Diagnosis of acrometastases frequently gets delayed due to the rarity of this condition and resultant low clinical suspicion. Possibility of metastatic disease should be entertained as an important differential diagnosis when patients with a history of cancer present with musculoskeletal symptoms. A systematic evaluation incorporating thorough clinical assessment, advanced imaging techniques like MRI and pathological examination is critical to establish the diagnosis.

Hazards of the Cytokine Storm and Cytokine-Targeted Therapy in Patients With COVID-19: Review.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has challenged medicine and health care on a global scale. Its impact and frightening mortality rate are in large part attributable to the fact that there is a lack of available treatments. It has been shown that in patients who are severely ill, SARS-CoV-2 can lead to an inflammatory response known as cytokine storm, which involves activation and release of inflammatory cytokines in a positive feedback loop of pathogen-triggered inflammation. Currently, cytokine storm is one of the leading causes of morbidity and mortality in SARS-CoV-2, but there is no proven treatment to combat this systemic response. OBJECTIVE: The aim of this paper is to study the cytokine storm response in SARS-CoV-2 and to explore the early treatment options for patients who are critically ill with the coronavirus disease (COVID-19) in the early stages of the pandemic by reviewing the literature. METHODS: A literature review was performed from December 1, 2000, to April 4, 2020, to explore and compare therapies that target cytokine storm among SARS-CoV-2 and prior coronavirus cases. RESULTS: A total of 38 eligible studies including 24 systematic reviews, 5 meta-analyses, 5 experimental model studies, 7 cohort studies, and 4 case reports matched the criteria. CONCLUSIONS: The severity of the cytokine storm, measured by elevated levels of interleukin-1B, interferon-γ, interferon-inducible protein 10, and monocyte chemoattractant protein 1, was associated with COVID-19 disease severity. Many treatment options with different targets have been proposed during the early stages of the COVID-19 pandemic, ranging from targeting the virus itself to managing the systemic inflammation caused by the virus and the excessive cytokine response. Among the different agents to manage cytokine storm in patients with COVID-19, there is developing support for convalescent plasma therapy particularly for patients who are critically ill or mechanically ventilated and resistant to antivirals and supportive care. Treatment options that were proposed in the beginning phases of the pandemic were multidimensional, and further research is needed to develop a more established treatment guideline.

Rlip Depletion Suppresses Growth of Breast Cancer.

RLIP76 (RAL-binding protein-1, Rlip) is a stress-protective mercapturic-acid-pathway transporter protein that also plays a key role in regulating clathrin-dependent endocytosis as a Ral effector. Targeted inhibition or depletion of Rlip causes regression of xenografts of many cancers and is capable of abrogating tumor formation in p53-null mice. This is associated with the reversion of the abnormal methylomic profile of p53-null mice to wild-type. In a query of The Cancer Genome Atlas (TCGA) databases, we found that Rlip expression was associated with poor survival and with significant differences in the frequencies of PIK3CA mutation, MYC amplification, and CDKN2A/B deletion, which were the most commonly mutated, amplified, and deleted genes, respectively, among TCGA breast cancer patients. We conducted the present study to further examine the effects of Rlip inhibition and to evaluate the in vitro and in vivo efficacy in breast cancer. Using immunogold electron microscopy, we found that plasma-membrane Rlip was accessible to cell-surface antibodies in the MCF7 (ER+) breast cancer cell line. Rlip depletion resulted in decreased survival of MCF7 and MDA-MB-231 cells and increased terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) positivity and DNA laddering, indicating apoptotic cell death. Additionally, in vitro knockdown of Rlip inhibited EGF endocytosis and WNT/MAPK signaling. Xenograft studies in nude mice showed regression of breast cancer via antisense-mediated depletion of Rlip mRNA as well as by anti-Rlip antibody. Finally, knockdown of Rlip by antisense locked nucleic acid oligonucleotides increased markers for apoptotic signaling and decreased markers for proliferation, angiogenesis, and cell cycling in MCF7 and MDA-MB-231luc xenografts. Our findings validate Rlip as an attractive target in breast cancer.

Extrapulmonary sarcoidosis in an atypical patient demographic.

Although it typically presents with cough and dyspnea due to pulmonary involvement, sarcoidosis is a multisystem granulomatous disease and therefore may present with extrapulmonary manifestations. Cutaneous manifestations are common, while hepatic sarcoidosis is uncommon and osseous manifestations are exceedingly rare. This article describes osseous, hepatic, and cutaneous manifestations due to sarcoidosis. The patient was diagnosed with sarcoidosis, treated with a dynamic hip screw implant with a derotational screw, and discharged on a new medication regimen: vitamin D, calcium supplements, alendronate, methotrexate, and hydroxychloroquine.

Combination of the histone deacetylase inhibitor vorinostat with bevacizumab in patients with clear-cell renal cell carcinoma: a multicentre, single-arm phase I/II clinical trial.

BACKGROUND: Class II histone deacetylase (HDAC) inhibitors induce hypoxia-inducible factor-1 and -2α degradation and have antitumour effects in combination with vascular endothelial growth factor (VEGF) inhibitors. In this study, we tested the safety and efficacy of the HDAC inhibitor vorinostat and the VEGF blocker bevacizumab in metastatic clear-cell renal cell carcinoma (ccRCC) patients previously treated with different drugs including sunitinib, sorafenib, axitinib, interleukin-2, interferon, and temsirolimus. METHODS: Patients with up to two prior regimens were eligible for treatment, consisting of vorinostat 200 mg orally two times daily × 2 weeks, and bevacizumab 15 mg kg-1 intravenously every 3 weeks. The primary end points were safety and tolerability, and the proportion of patients with 6 months of progression-free survival (PFS). Correlative studies included immunohistochemistry, FDG PET/CT scans, and serum analyses for chemokines and microRNAs. RESULTS: Thirty-six patients were enrolled, with 33 evaluable for toxicity and efficacy. Eighteen patients had 1 prior treatment, 13 patients had 2 prior treatments, and 2 patients were treatment naïve. Two patients experienced grade 4 thrombocytopenia and three patients had grade 3 thromboembolic events during the course of exposure. We observed six objective responses (18%), including one complete response and five partial responses. The proportion of patients with PFS at 6 months was 48%. The median PFS and overall survival were 5.7 months (confidence interval (CI): 4.1-11.0) and 13.9 months (CI: 9.8-20.7), respectively. Correlative studies showed that modulation of specific chemokines and microRNAs were associated with clinical benefit. CONCLUSIONS: The combination of vorinostat with bevacizumab as described is relatively well tolerated. Response rate and median PFS suggest clinical activity for this combination strategy in previously treated ccRCC.

Construct validation of the key components of Fundamental Skills of Robotic Surgery (FSRS) curriculum--a multi-institution prospective study.

BACKGROUND: Recent incorporation of simulation in surgical training necessitates developing validated platforms for training and assessment. A tool should fulfill the fundamental criteria of validation. OBJECTIVE: To report the ability of a simulation-based robotic training curriculum-Fundamental Skills of Robotic Surgery (FSRS)-to assess and distinguish between different performance levels of operator experience (construct validity). MATERIALS AND METHODS: This is a prospective multicenter observational study. Participants were classified as novice (0 robotic cases performed) and experts (>150 robotic cases performed). All participants were required to complete 4 key tasks in a previously validated FSRS curriculum: ball placement, coordinated tool control, fourth arm control, and needle handling and exchange. Using the metrics available in the simulator software, the performances of each group were compared to evaluate construct validation. RESULTS: A convenience cohort of 61 surgeons participated. Novice group (n = 49) consisted of 41 fellows/residents/medical students and 8 trained open/laparoscopic surgeons, whereas expert group consisted of 12 surgeons. The novice group had no previous robotic console experience, whereas the expert group had >150 prior robotic cases experience. An overall significant difference was observed in favor of the expert group in 4 skill sets (p < 0.05). Time to complete all 4 tasks was significantly shorter in the expert group (p < 0.001). The expert group displayed significantly lesser tool collision (p = 0.002) and reduced tissue damage (p < 0.001). In performing most tasks, the expert group's camera (p < 0.001) and clutch usage (p < 0.001) was significantly greater when compared with the novice group. CONCLUSION: The components of the FSRS curriculum showed construct validity. This validation would help in effectively implementing this curriculum for robot-assisted surgical training.

Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC).

OBJECTIVE: To determine short-term health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC) using the Bladder Cancer Index (BCI) and European Organisation for Research and Treatment of Cancer (EORTC) Body Image Scale (BIS). PATIENTS AND METHODS: All patients undergoing RARC were enrolled in a quality assurance database. The patients completed two validated questionnaires, BCI and BIS, preoperatively and at standardised postoperative intervals. The primary outcome measure was difference in interval and baseline BCI and BIS scores. Complications were identified and classified by Clavien grade. RESULTS: In all, 43 patients completed pre- and postoperative questionnaires There was a decline in the urinary domain at 0-1 month after RARC (P = 0.006), but this returned to baseline by 1-2 months. There was a decline in the bowel domain at 0-1 month (P < 0.001) and 1-2 months (P = 0.024) after RARC, but this returned to baseline by 2-4 months. The decline in BCI scores was greatest for the sexual function domain, but this returned to baseline by 16-24 months after RARC. Body image perception using BIS showed no significant change after RARC except at the 4-10 months period (P = 0.018). CONCLUSIONS: Based on BCI and BIS scores HRQL outcomes after RARC show recovery of urinary and bowel domains ≤6 months. Longer follow-up with a larger cohort of patients will help refine HRQL outcomes.

Effectiveness of a dedicated robot-assisted surgery training program.

INTRODUCTION: Robot-assisted surgery (RAS) has been integrated into the surgical armamentarium and generated wide-spread interest among practicing, non-robotic surgeons (NRS). While methods for training novice non-robotic surgeons have emerged, the effectiveness of these training programs has endured minimal scrutiny. This study aims to establish effectiveness of the RAST training program. MATERIALS AND METHODS: A formal RAST program was established at Roswell Park Cancer Institute (RPCI) in 2008. From July 2010 to October 2012, 43 non-robotic surgeons participated in the program. The 1 to 4 week program included the validated fundamentals skills of robotic surgery (FSRS) curriculum, hands-on bedside trouble-shooting training, case observation with an expert robotic surgeon, hands on surgical training (HoST) procedure modules, da Vinci robotic surgical hands-on experience and finally a compulsory animal laboratory utilizing the da Vinci. As part of our training and credentialing quality assurance program, all participants were prospectively evaluated employing a survey. This survey aimed to evaluate the enduring impact of the RAST through time-sensitive interventions that allowed participants to reacclimatize themselves to their prospective practice as independently performing surgeons. RESULTS: The survey responses received from the participating NRS were collected over 27 months, with a response rate of 84%. The average follow up period post-RAST completion was 6 months (2-19). Overall, participants felt that the FSRS curriculum (81%), bedside trouble shooting (7%), and animal laboratory (53%) were beneficial program features that enabled NRS to become adequately acquainted with the basic principles of RAS. Approximately 5 weeks after RAST program completion, 64% of surgeons performed robot-assisted surgery. The two most commonly performed procedures were robot-assisted radical prostatectomy and gastrointestinal surgeries where eight surgeons performed independently while 12 performed procedures under the supervision of an expert robotic surgeon. The overall conversion rate to open was reported to be 1.3%. CONCLUSIONS: A dedicated surgical training program focused on learning key steps of RAS enabled most participants to successfully incorporate and maintain their RAS skills in clinical practice.

Understanding avoidance, refusal, and abandonment of chemotherapy before and after cystectomy for bladder cancer.

OBJECTIVE: To analyze trends in perioperative chemotherapy and optimize use of neoadjuvant chemotherapy for bladder cancer. METHODS: From 2005-2012, 284 consecutive patients underwent robot-assisted radical cystectomy at our facility. Patients with disease ≥ T2 and nodal involvement and positive surgical margins were reviewed and considered candidates for referral to medical oncology for chemotherapy. The study was conducted in two phases: phase 1 included 242 consecutive patients between 2005 and 2011, and phase 2 analyzed the effect of changes in 42 patients during a 1-year period (2011-2012). RESULTS: In phase 1, 148 patients (61%) were candidates for neoadjuvant chemotherapy (NAC). Consultation for NAC was sought for 44 patients (29%), and 104 (71%) did not receive consultation. Of the 44 patients, 36% received NAC, 7% refused, 32% were recommended for immediate cystectomy, and 25% did not receive NAC for other reasons. Phase 2 was more stringent, with a multidisciplinary approach. Significant improvement in referral and NAC use was seen. About 78% vs 30% of patients were seen by medical oncology for consideration of NAC before robot-assisted radical cystectomy and 71% vs 36% received NAC compared with phase 1. The NAC utilization rate improved from 10.8% to 55% over 1 year with a diligent multidisciplinary approach. Medical comorbidities were the main reason for patients not receiving adjuvant chemotherapy (AC; 30% and 33%). CONCLUSION: A multidisciplinary approach and coordination of services can help optimize the use of neoadjuvant chemotherapy for bladder cancer.

Simulation-based robot-assisted surgical training: a health economic evaluation.

OBJECTIVE: To determine the overall cost effectiveness of surgical skills training on Robotic Surgical Simulator (RoSS). METHODS: This study evaluates the cost analysis of utilizing RoSS for robot-assisted surgical training, at Roswell Park Center for Robotic Surgery. Trainees were queried for time spent on the RoSS console over a period of 1 year, starting from June 2010 to June 2011. Time spent was converted to training time consumed on robotic console, resulting in loss of OR time and revenue. The mechanical durability of the RoSS was also determined. RESULTS: 105 trainees spent 361 h on the RoSS. This duration converted to 73 robot-assisted radical prostatectomy cases, and 72 animal lab sessions. RoSS prevented a potential loss of $600,000, while 72 animal labs would have cost more than $72,000 without including initial robot installation, annual maintenance and personnel expenses. The mechanical durability testing determined breakdown at 180 and 360 h for master control and pinch device, which were repaired under warranty. CONCLUSION: RoSS is a cost effective surgical simulator for implementation of a simulation-based robot-assisted surgical training program.

Fundamental skills of robotic surgery: a multi-institutional randomized controlled trial for validation of a simulation-based curriculum.

OBJECTIVE: To develop and establish effectiveness of simulation-based robotic curriculum--fundamental skills of robotic surgery (FSRS). METHODS: FSRS curriculum was developed and incorporated into a virtual reality simulator, Robotic Surgical Simulator (RoSS). Fifty-three participants were randomized into an experimental group (EG) or control group (CG). The EG was asked to complete the FSRS and 1 final test on the da Vinci Surgical System (dVSS). The dVSS test consisted of 3 tasks: ball placement, suture pass, and fourth arm manipulation. The CG was directly tested on the dVSS then offered the chance to complete the FSRS and re-tested on the dVSS as a crossover (CO) group. RESULTS: Sixty-five percent of participants had never formally trained using laparoscopic surgery. Ball placement: the EG demonstrated shorter time (142 vs 164 seconds, P = .134) and more precise (1.5 vs 2.5 drops, P = .014). The CO took less time (P <.001) with greater precision (P <.001). Instruments were rarely lost from the field. Suture pass: the EG demonstrated better camera utilization (4.3 vs 3.0, P = .078). Less instrument loss occurred (0.5 vs 1.1, P = .026). Proper camera usage significantly improved (P = .009). Fourth arm manipulation: the EG took less time (132 vs 157 seconds, P = .302). Meanwhile, loss of instruments was less frequent (0.2 vs 0.8, P = .076). Precision in the CO improved significantly (P = .042) and camera control and safe instrument manipulation showed improvement (1.5 vs 3.5, 0.2 vs 0.9, respectively). CONCLUSION: FSRS curriculum is a valid, feasible, and structured curriculum that demonstrates its effectiveness by significant improvements in basic robotic surgery skills.

The first 100 consecutive, robot-assisted, intracorporeal ileal conduits: evolution of technique and 90-day outcomes.

BACKGROUND: Robot-assisted radical cystectomy (RARC) has evolved over the last few years to become an acceptable alternative option to open radical cystectomy. Most series of RARC used an open approach to urinary diversion. Even though robot-assisted intracorporeal urinary diversion (RICUD) is the natural extension of RARC, few centers have reported their experiences with RICUD in general, and in particular, of robot-assisted intracorporeal ileal conduits (RICIC). OBJECTIVE: To report our experience with RICIC using the Marionette technique. DESIGN, SETTING, AND PARTICIPANTS: The first 100 consecutive patients who underwent RARC and RICIC, and had ≥ 3 mo of postoperative follow-up were included in this study. Patients were divided into four groups of 25 patients each to study the evolution of our surgical technique. INTERVENTION: RICIC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Intraoperative, pathologic, and 90-d postoperative outcomes for the four groups and the overall cohort were compared using the Fisher exact test (categorical variables) and the Kruskal-Wallis test (continuous variables). Continuous variables were reported as median (range) and categorical variables were specified as frequency (percentage). RESULTS AND LIMITATIONS: Overall operative and specific diversion times were 352 and 123 min, respectively. Estimated blood loss was 300 ml, lymph node yield was 24, and positive surgical margin rate was 4%. Length of hospital stay increased from 7 d for group 1 to 9 d for group 4. The overall 90-d complication rate was 81%; 19% of complications were high grade. Infections were the most common complications, representing 31% of all complications. There were no statistically significant intergroup differences except in diversion time, intraoperative transfusions, and length of stay. CONCLUSIONS: RICIC diversion is safe, feasible, and reproducible. Larger series with longer follow-up are needed to validate the procedure and define its place in the minimally invasive urologic armamentarium. Quality of life studies need to be conducted to compare benefits of intracorporeal urinary diversion.

Short-term patient-reported quality of life after robot-assisted radical cystectomy using the Convalescence and Recovery Evaluation.

OBJECTIVE: To determine the short-term health status of patients after robot-assisted radical cystectomy using the Convalescence and Recovery Evaluation (CARE). Radical cystectomy and urinary diversion in patients with invasive bladder cancer can have a significant effect on patients' quality of life. METHODS: A total of 91 patients completed the CARE preoperatively and postoperatively. The CARE scores were calculated from postoperative day 7 to 90. Outcome measures were calculated using the CARE difference index (CDI), defined as the difference between the baseline CARE and postoperative day 7 CARE scores. The primary outcome was the time taken to recover 90% of the CDI. RESULTS: The mean age at robot-assisted radical cystectomy was 69 years (range 42-86). Of the 91 patients, 68 (74%) were men, 38 underwent extracorporeal urinary diversion, 52 underwent intracorporeal urinary diversion, and 1 underwent no diversion. A comparison of the preoperative and postoperative day 7 scores demonstrated a 48% decline in the total CARE score. The decline in specific CARE domains was 14%, 34%, 56%, and 66% against baseline for the cognition, pain, gastrointestinal, and activity domains, respectively. The mean time to recover 90% of the CDI for the total CARE score was 63 days. The mean time to recover 90% of the CDI for the pain, cognition, and activity domains was 33, 57, and 82 days, respectively. Patients did not recover 90% of the CDI for the gastrointestinal domain within the 90-day follow-up period. CONCLUSION: Patients who underwent robot-assisted radical cystectomy approached preoperative baseline levels within 90 days using the CARE in the total CARE, pain, cognition, and activity domains but not in the gastrointestinal domain.

Status of Robot-Assisted Radical Cystectomy (RARC) in 2012.

Robot-assisted radical cystectomy (RARC) for bladder cancer is increasingly becoming popular in specialist centres around the world. RARC has the advantage of being minimally invasive and also the dexterity of the instruments allow reconstruction such as ileal conduit urinary diversion or neobladder formation. Starting from the initial series demonstrating the feasibility of RARC and extended pelvic lymph node dissection, we now have mature series demonstrating equal oncological and functional outcomes in the medium term follow-up. In addition, literature suggests decreased hospital stay, less blood loss equating to less blood transfusion and a trend towards decreased complications as well. In the near future we would anticipate further refinement and reduced operating times with increased benefits for the patient undergoing RARC.