Incidental prostate carcinoma after single-port robot-assisted simple prostatectomy: a multi-institutional report (SPARC).

BACKGROUND: Single-port robot-assisted simple prostatectomy is a minimally invasive alternative for patients with large benign prostatic hyperplasia with severe symptoms and/or failure of medical treatment. In recent literature, the rate of incidental prostate cancer after simple prostatectomy ranges from 1.8% to 13.0%. Our objective is to report the rate of incidental prostate cancer after single-port robot-assisted simple prostatectomy and to compare our findings to other approaches. METHODS: A Single-Port Advanced Research Consortium [SPARC] multi-institutional retrospective analysis of all initial consecutive single-port robot-assisted simple prostatectomy cases performed from 2019 to 2023 by eleven surgeons from six centers. Our primary outcome was the rate of incidental prostate cancer in adenoma specimens. We used descriptive statistics to analyze the data. RESULTS: A total of 235 cases were performed successfully without conversions or additional ports. Eleven patients (4.6%) were found to have incidental prostate cancer on pathological analysis. The median percentage of tissue involved by the tumor was 5%. The overall rate of clinically significant prostate cancer was 2.1%. Most cases were Gleason Grade Group 1 (55%). Those with Grade Group ≤3 were subsequently managed with active surveillance with a median follow-up of 17 months. A patient with Gleason Grade Group 4 underwent an uncomplicated multi-port robot-assisted radical prostatectomy with satisfactory functional and oncological outcomes. CONCLUSIONS: Initial multi-institutional experience with single-port robot-assisted simple prostatectomy showed an incidental prostate cancer rate of 4.6%, comparable to MP, laparoscopic, and open techniques.

MRI and active surveillance: thoughts from across the pond.

In the United States (US), urological guidelines recommend active surveillance (AS) for patients with low-risk prostate cancer (PCa) and endorse it as an option for those with favorable intermediate-risk PCa with a > 10-year life expectancy. Multiparametric magnetic resonance imaging (mpMRI) is being increasingly used in the screening, monitoring, and staging of PCa and involves the combination of T2-weighted, diffusion-weighted, and dynamic contrast-enhanced T1-weighted imaging. The American Urological Association (AUA) guidelines provide recommendations about the use of mpMRI in the confirmatory setting for AS patients but do not discuss the timing of follow-up mpMRI in AS. The National Comprehensive Cancer Network (NCCN) discourages using it more frequently than every 12 months. Finally, guidelines state that mpMRI can be used to augment risk stratification but should not replace periodic surveillance biopsy. In this review, we discuss the current literature regarding the use of mpMRI for patients with AS, with a particular focus on the approach in the US. Although AS shows a benefit to the addition of mpMRI to diagnostic, confirmatory, and follow-up biopsy, there is no strong evidence to suggest that mpMRI can safely replace biopsy for most patients and thus it must be incorporated into a multimodal approach. CLINICAL RELEVANCE STATEMENT: According to the US guidelines, regular follow-ups are important for men with prostate cancer on active surveillance, and prostate MRI is a valuable tool that should be utilized, in combination with PSA kinetics and biopsies, for monitoring prostate cancer. KEY POINTS: According to the US guidelines, the addition of MRI improves the detection of clinically significant prostate cancer. Timing interval imaging of patients on active surveillance remains unclear and has not been specifically addressed. MRI should trigger further work-ups, but not replace periodic follow-up biopsies, in men on active surveillance.

Predictors of Same-day Discharge After Single-Port Transvesical Enucleation of the Prostate.

OBJECTIVE: To determine the rate of outpatient cases and identify predictors for same-day discharge (SDD) after single-port transvesical enucleation of the prostate (STEP). METHODS: Retrospective analysis of all consecutive STEP cases performed at a single center by 3 surgeons from February 2019 to October 2023. The cohort was categorized into SDD cases (<8 hours until discharge) and inpatient cases. Group comparisons were made and logistic regression was used to identify predictors of SDD. RESULTS: A total of 152 STEP cases were performed successfully without additional ports or conversions. Fifty-two patients were pre-planned admissions, leaving 100 planned outpatient cases, of which 86% were discharged on the same day (median length of stay of 4.7 hours). Comparing the groups, inpatient cases were older, had higher Charlson Comorbidity Index (CCI) scores, higher estimated blood loss (EBL) during surgery, and more intraoperative complications than SDD patients. Univariate logistic regression identified age and CCI as the predictors associated with SDD after STEP. Notably, there were no major postoperative complications or readmissions in either group. CONCLUSION: In our 4-year experience with STEP, lower age and CCI score were significant predictors of SDD. The comprehensive evaluation criteria for discharge foster a safe recovery at home, coupled with a 0% rate of major postoperative complications and readmissions. These findings underscore the safety and efficacy of STEP, guiding patient counseling and surgeon expectations.

Single-port Transvesical Robot-Assisted Simple Prostatectomy: Surgical Technique and Clinical Outcomes.

BACKGROUND: Surgical management of large prostatic adenomas can be performed via open, endoscopic, or robotic approaches. A low-profile single-port (SP) robot was built to work in confined areas (ie, the bladder) and regionalize surgery. OBJECTIVE: To describe the novel SP transvesical (TV) robot-assisted simple prostatectomy (RASP) and report clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: SP TV RASP cases were performed in an academic hospital by two surgeons from 2019 to 2023. A total of 117 cases were performed, and data from patients with at least 12 mo of follow-up were analyzed. The inclusion criterion was severe obstructive urinary symptoms or catheter-dependent urinary retention due to large prostates with volume >80 ml. SURGICAL PROCEDURE: The procedure consisted of two main steps through a single 3-cm suprapubic incision: first, enucleation of the adenoma, and second, a 360° bladder mucosal flap reconstruction. No drains or continuous bladder irrigation was used routinely. MEASUREMENTS: Intraoperative parameters, pre- and postoperative uroflowmetry, and 1-yr clinical outcomes were assessed. We used descriptive statistics to analyze the data. RESULTS AND LIMITATIONS: All procedures were completed successfully without additional ports or conversions. The median console time and estimated blood loss were 107 min and 100 ml, respectively. Transfusion rate was 0%. Intraoperative complications included two suspected air emboli attributed to high insufflation pressures. There were no major postoperative complications. In total, 95.8% were discharged within the first 24 h, with a median length of stay and pain score of 5 h and 3/10, respectively. There was persistent improvement in the median International Prostate Symptom Score and flow rate after 1 yr. The median Sexual Score Inventory for Men score was 20 at 12 mo. Our study is limited by its retrospective nature and cohort size. CONCLUSIONS: SP TV RASP is a feasible alternative for the management of severe benign prostatic hyperplasia that promotes fast recovery and demonstrates 1-yr improvement in urinary function. PATIENT SUMMARY: Single-port transvesical robot-assisted simple prostatectomy is a minimally invasive alternative for the treatment of large benign prostatic growth. A single robotic arm goes through a small incision in the skin and bladder to extract the obstructive prostatic tissue. Afterward, reconstruction of the area is done to decrease bleeding and improve postoperative symptoms. We found that patients recover quickly and have excellent clinical results with a low risk of complications.

The Feasibility and Value of a Focal Therapy Multidisciplinary Tumor Board, Including Radiographic and Pathological Overreads in Refining the Selection for High Intensity Focused Ultrasound in Prostate Cancer Patients.

INTRODUCTION: Focal therapy for prostate cancer is increasingly recognized as an acceptable therapeutic option in well-selected men. A focal therapy multidisciplinary tumor board geared toward improving patient selection is a novel concept which has not been reported. We describe our institution's initial experience with a multidisciplinary tumor board for focal therapy and its outcomes in terms of patient selection. METHODS: This was a single-center, prospective study of patients referred to a multidisciplinary tumor board. All prostate MRIs were re-reviewed by a single radiologist with >10 years of experience, and the number, size, location, and Prostate Imaging Reporting & Data System scores of lesions visible on MRI were recorded and compared to the original report. Outside histopathology, when requested, was also re-reviewed for cancer grade groups and adverse pathological features. A descriptive statistical analysis was performed. RESULTS: Seventy-four patients were presented at our multidisciplinary tumor board (January-October 2022). Sixty-seven patients were treatment naïve, while 7 had prior radiation±androgen deprivation therapy. MRI overread was performed on all treatment-naïve patients (67/74 [91%]), while pathology overreads were performed on 14/74 (19.9%). Following multidisciplinary tumor board, 19 patients (25.6%) were deemed suitable candidates for focal therapy. A total of 24 patients (35.8%) were not deemed candidates for high intensity focused ultrasound focal therapy based exclusively on findings identified at MRI overread. Pathology re-review changed management for 3/14 patients, with two-thirds being downgraded to grade group 1 disease and opting for active surveillance. CONCLUSIONS: Multidisciplinary tumor board for focal therapy is feasible. MRI overread is an essential component of this process and demonstrates significant findings that alter eligibility or management in over a third of patients.

Single Port Robotic Kidney Autotransplantation: Initial Case Series and Description of Technique.

PURPOSE: Minimally invasive kidney autotransplantation (KAT) has demonstrated reduced morbidity, however multiport robotic approach required patient repositioning and multiple sets of incisions. We present our initial series of single-port (SP) robotic KAT, ideal for multi-quadrant surgeries, and aim to evaluate feasibility and safety of the novel approach. METHODS: Between 2018 and 2022, 8 consecutive patients underwent SP KAT using the DaVinci SP platform. Patient clinicopathologic variables and perioperative outcomes were recorded. Indications for KAT include complex or recurrent ureteral stricture, ureteral avulsion, and chronic visceral pain due to multiple etiologies. RESULTS: All SP KATs were successfully performed without repositioning or conversion to open. Operative times ranged from 366 to 701 minutes, warm and cold ischemia times between 4 to 10 minutes and 86 to 209 minutes, respectively. Median hospital length of stay was 3 days. At a median of 13 months follow-up, latest postoperative GFRs were stable, ranging from +23% to -10%. There were no complications. CONCLUSION: We demonstrate our single port, multiquadrant robotic kidney auto transplantation technique performed though a single incision further reducing surgical morbidity. All cases were completed successfully without conversion or loss of graft function. All patients reported resolution of flank pain and no radiological evidence of urinary obstruction on follow up.

Longitudinal analysis of YouTube videos discussing post-prostatectomy erectile dysfunction.

BACKGROUND: YouTube is heavily utilized by patients as an educational resource, but this content can be fraught with misinformation. We sought to characterize the quality of videos on YouTube discussing postprostatectomy erectile dysfunction and to evaluate metrics associated with retaining a top position in search results over time. METHODS: In October 2019, we watched the first 100 YouTube videos using the search query "radical prostatectomy erectile dysfunction." Videos not relevant to the topic were excluded. Video metrics were collected, and content quality was evaluated using the DISCERN instrument. In June 2022, the search was repeated and video metrics were updated. Video characteristics were associated with search rank and the ability to remain in the top 100 spots using the Pearson correlation coefficient (r) and logistic regression, respectively. RESULTS: We included 81 videos which amassed 529,428 views in 2019. The median total DISCERN score was 29 (IQR 21-42), which is interpreted as a poor quality video. Self-promotion or commercial bias was present in 42 videos (51.9%); false claims were present in 16 (19.8%). There was no correlation between DISCERN score and search rank (r = 0.08, p = 0.49). In 2022, 15 videos remained in the top 100 search results and had a higher median DISCERN score than videos no longer in the top 100 (46 vs. 28.5, p = 0.01). Each additional DISCERN point was associated with a 7% higher odds of remaining in the top 100 (OR 1.07, 95% CI 1.01-1.11, p = 0.003). CONCLUSIONS: The quality of the top 100 YouTube videos discussing postprostatectomy erectile dysfunction is low. Higher quality videos had a higher odds of remaining in the top 100 search results over time but do not correlate with the order in which they are ranked.

Minimally-Invasive Radical Nephrectomy and Left-Sided Level II Caval Thrombectomy: A New Combined Technique.

OBJECTIVE: To present a combined multiport robotic and open approach for left radical nephrectomy and inferior vena cava thrombectomy in patients with a primary left renal mass and level II inferior vena cava (IVC) tumor thrombus. METHODS: A 69-year-old female was diagnosed with an 8.9cm left renal neoplasm with level II IVC thrombus. She was placed in the left-side-up flank position. The descending colon was mobilized and the left gonadal vein was identified. The left renal vein was identified and fully dissected. The left renal artery was dissected and stapled. The kidney was dissected and left detached with exception of the renal vein. The robot was undocked and the patient was positioned supine. Through a supra-umbilical midline incision, the ascending colon and duodenum were mobilized medially. The right renal vein and IVC were identified and dissected to the level of hepatic veins. The IVC was clamped using a Satinsky clamp. The right renal artery and vein remained patent during thrombectomy. The IVC was opened, the thrombus was evacuated, and IVC was closed. Clamps were removed and the kidney was removed. RESULTS: Operative time was 405 minutes. IVC clamp time was 14 minutes. Estimated blood loss was 500cc. Recovery was uncomplicated. Length of stay was 4 days. Pathology showed clear cell carcinoma with negative margins. CONCLUSION: IVC thrombectomy is challenging on left sided tumors. Combining a robotic and open technique together is feasible and allows a smaller supra-umbilical midline incision compared to standard open incision.

Single-port transvesical versus open simple prostatectomy: a perioperative comparative study.

OBJECTIVE: To compare the initial perioperative outcomes of single-port transvesical simple prostatectomy (SP RASP) patients to those of open simple prostatectomy (OSP). PATIENTS AND METHODS: Perioperative data from 42 consecutive patients with BPH who underwent SP RASP were prospectively reviewed. Similarly, data from forty-three consecutive patients who underwent the standard OSP, were retrospectively collected. Through direct suprapubic bladder access, prostatic enucleation was performed using the prostatic capsule as a landmark. Then a complete vesicourethral mucosal advancement flap was accomplished. OSP was performed according to the standard approach. Demographics, Intra- and perioperative data were analyzed and assessed with a descriptive analysis. RESULTS AND LIMITATIONS: Baseline characteristics were comparable between the two groups, except for the preoperative median post-void residual volume, which was higher in the OSP group (p = 0.004). The SP RASP group had less intraoperative estimated blood loss (p < 0.001), no need for continuous bladder irrigation (p < 0.001), and less in-hospital opioid use (p < 0.001). Patients in the SP RASP group were discharged on postoperative day zero, compared to a median of 2 days for OSP (p < 0.001). The median Foley catheter duration was 7 days for SP RASP, compared to a median of 10 days for OSP (p < 0.001). SP RASP group had fewer postoperative complications, however, this did not reach statistical significance. CONCLUSION: SP RASP is an alternative approach in treating surgical BPH. It may offer patients less morbidity in comparison to OSP.

Long-term comparative outcomes of partial nephrectomy and cryoablation in patients with solitary kidneys: a single-center analysis.

BACKGROUND: Patients with solitary kidneys are amenable to postoperative acute kidney injury (AKI) after PN. We compared the functional and oncological outcomes of cryoablation (CA) and PN in patients with a solitary kidney and a cT1a renal mass. METHODS: From a single-institution series, we analyzed 74 patients (31 PN, 43 CA) with a solitary kidney who underwent treatment for a cT1a renal mass. The functional outcomes were AKI and estimated glomerular filtration rate (eGFR) preservation. Oncological outcomes were recurrence and death. Linear mixed-effects and logistic regression models were used for functional outcomes analysis, whereas oncological outcomes were analyzed using the Kaplan-Meier method. RESULTS: Median follow-up was 63.9 months. PN group had lower median age (59 years vs. 68, P<0.001) and larger median tumor size (2.80 cm vs. 2.0, p =0.003). AKI was more common in the PN group on postoperative day 1 (58% vs. 2.8%, P<0.001). However, only one patient in the PN group required temporary dialysis in the perioperative period. eGFR preservation was similar at postoperative 3 months (89% vs. 90%, P=0.083), or 12 months (85% vs. 94%, P=0.2) follow-up. CA group had higher recurrence rate (29% vs. 3.2%, P=0.005), and worse recurrence-free survival (P=0.027). Overall survival (OS) was comparable (P=0.31). CONCLUSIONS: In a solitary kidney setting, CA is associated with a lower risk of AKI at postoperative day 1 compared to PN. Functional outcome is comparable upon longer follow-up. The local recurrence rates are significantly higher in the CA group with no significant difference in OS.

A Global Survey of Ergonomics Practice Patterns and Rates of Musculoskeletal Pain Among Urologists Performing Retrograde Intrarenal Surgery.

Purpose: Retrograde intrarenal surgery (RIRS) requires urologists to adopt an awkward body posture for long durations. Few urologists receive training in ergonomics despite the availability of ergonomic best practices utilized by other surgical specialties. We characterize ergonomic practice patterns and rates of musculoskeletal (MSK) pain among urologists performing RIRS. Methods: A web-based survey was distributed through the Endourological Society, the European Association of Urology, and social media. Surgeon anthropometrics and ergonomic factors were compared with ergonomic best practices. Pain was assessed with the Nordic Musculoskeletal Questionnaire (NMQ). Results: Overall, 519 of 526 participants completed the survey (99% completion rate). Ninety-three percent of urologists consider ergonomic factors when performing RIRS to reduce fatigue (68%), increase performance (64%), improve efficiency (59%), and reduce pain (49%). Only 16% received training in ergonomics. Residents/fellows had significantly lower confidence in ergonomic techniques compared with attending surgeons with any career length. Adherence to proper ergonomic positioning for modifiable factors was highly variable. On the NMQ, 12-month rates of RIRS-associated pain in ≥1 body part, pain limiting activities of daily living (ADLs), and pain requiring medical evaluation were 81%, 51%, and 29%, respectively. Annual case volume >150 cases (odds ratio [OR] 0.55 [0.35-0.87]) and higher adherence to proper ergonomic techniques (OR 0.67 [0.46-0.97]) were independently associated with lower odds of pain. Limitations include a predominantly male cohort, which hindered the ability to assess gender disparities in pain and ergonomic preferences. Conclusions: Adherence to ergonomic best practices during RIRS is variable and may explain high rates of MSK pain among urologists. These results underscore the importance of utilizing proper ergonomic techniques and may serve as a framework for establishing ergonomic guidelines for RIRS.

Single-Port Donor Nephrectomy via Modified Pfannenstiel Incision: Initial Preclinical Experience in a Cadaveric Model and Description of Technique.

Objective: To describe the surgical technique for the single-port (SP) transperitoneal donor nephrectomy (DN) through a modified Pfannenstiel incision using the Da Vinci SP® surgical system (Intuitive Surgical, Sunnyvale, CA) on a cadaver. Patients and Methods: In a male cadaver, the SP surgical system was used to perform transperitoneal DN. A 3-cm modified Pfannenstiel incision was made. Through the incision GelPOINT mini (Applied Medical, Rancho Santa Margarita, CA) was inserted. The floating docking technique was used. Through the gel port, the dedicated 25-mm multichannel port and a 12-mm assistant port were introduced. The surgical steps for DN were performed in the following order: (1) mobilization of the colon, (2) identification of psoas muscle, ureter, and the gonadal vein, (3) hilum dissection, (4) perirenal dissection, (5) stapling the renal artery and renal vein, and (6) removal of the kidney through the enlarged incision. Results: Transperitoneal SP DN was completed without any complications or capsulotomy. Additional ports were not needed. The total operative time was 63 minutes and 54 seconds. A good-quality kidney was harvested. Renal artery length was 4 cm. Conclusion: We demonstrated the feasibility of SP transperitoneal DN through modified Pfannenstiel incision, using the novel SP robotic platform. Further assessment is necessary in a clinical setting.

Using Competing Risk of Mortality to Inform the Transition from Prostate Cancer Active Surveillance to Watchful Waiting.

BACKGROUND: For men on active surveillance (AS) for prostate cancer (PCa), disease progression and age-related changes in health may influence decisions about pursuing curative treatment. OBJECTIVE: To evaluate the predicted PCa and non-PCa mortality at the time of reclassification among men on AS, to identify clinical criteria for considering a transition from AS to watchful waiting (WW). DESIGN, SETTING, AND PARTICIPANTS: Patients enrolled in a large AS program who experienced biopsy grade reclassification (Gleason grade increase) were retrospectively examined. All patients who had complete documentation of medical comorbidities at reclassification were included. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A validated model was used to assess 10- and 15-yr untreated PCa and non-PCa mortalities based on patient comorbidities and PCa clinical characteristics. We compared the ratio of predicted PCa mortality with predicted non-PCa mortality ("predicted mortality ratio") and divided patients into four risk tiers based on this ratio: (1) tier 1 (ratio: >0.33), (2) tier 2 (ratio 0.33-0.20), (3) tier 3 (ratio 0.20-0.10), and (4) tier 4 (ratio <0.10). RESULTS AND LIMITATIONS: Of the 344 men who were reclassified, 98 (28%) were in risk tier 1, 85 (25%) in tier 2, 93 (27%) in tier 3, and 68 (20%) in tier 4 for 10-yr mortality. Fifteen-year risk tiers were distributed similarly. The 23 (6.7%) men who met the "transition triad" (age >75 yr, Charlson Comorbidity Index >3, and grade group ≤2) had a 14-fold higher non-PCa mortality risk and a lower predicted mortality ratio than those who did not (0.07 vs 0.23, p < 0.001). The primary limitations of our study included its retrospective nature and the use of predicted mortalities. CONCLUSIONS: At reclassification, nearly half of patients had a more than five-fold and one in five patients had a more than ten-fold higher risk of non-PCa death than patients having a risk of untreated PCa death. Despite a more significant cancer diagnosis, a transition to WW for older men with multiple comorbidities and grade group <3 PCa should be considered. PATIENT SUMMARY: Men with favorable-risk prostate cancer and life expectancy of >10 yr are often enrolled in active surveillance, which entails delay of curative treatment until there is evidence of more aggressive disease. We examined a group of men on active surveillance who developed more aggressive disease, and found, nevertheless, that the majority of these men continued to have a dramatically higher risk of death from non-prostate cancer causes than from prostate cancer based on a risk prediction tool. For men older than 75 yr, who have multiple medical conditions and who do not have higher-grade cancer, it may be reasonable to reconsider the need for curative treatment given the low risk of death from prostate cancer compared with the risk of death from other causes.

Performance of a Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography-Derived Risk-Stratification Tool for High-risk and Very High-risk Prostate Cancer.

Importance: Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) can detect low-volume, nonlocalized (ie, regional or metastatic) prostate cancer that was occult on conventional imaging. However, the long-term clinical implications of PSMA PET/CT upstaging remain unclear. Objectives: To evaluate the prognostic significance of a nomogram that models an individual's risk of nonlocalized upstaging on PSMA PET/CT and to compare its performance with existing risk-stratification tools. Design, Setting, and Participants: This cohort study included patients diagnosed with high-risk or very high-risk prostate cancer (ie, prostate-specific antigen [PSA] level >20 ng/mL, Gleason score 8-10, and/or clinical stage T3-T4, without evidence of nodal or metastatic disease by conventional workup) from April 1995 to August 2018. This multinational study was conducted at 15 centers. Data were analyzed from December 2020 to March 2021. Exposures: Curative-intent radical prostatectomy (RP), external beam radiotherapy (EBRT), or EBRT plus brachytherapy (BT), with or without androgen deprivation therapy. Main Outcomes and Measures: PSMA upstage probability was calculated from a nomogram using the biopsy Gleason score, percentage positive systematic biopsy cores, clinical T category, and PSA level. Biochemical recurrence (BCR), distant metastasis (DM), prostate cancer-specific mortality (PCSM), and overall survival (OS) were analyzed using Fine-Gray and Cox regressions. Model performance was quantified with the concordance (C) index. Results: Of 5275 patients, the median (IQR) age was 66 (60-72) years; 2883 (55%) were treated with RP, 1669 (32%) with EBRT, and 723 (14%) with EBRT plus BT; median (IQR) PSA level was 10.5 (5.9-23.2) ng/mL; 3987 (76%) had Gleason grade 8 to 10 disease; and 750 (14%) had stage T3 to T4 disease. Median (IQR) follow-up was 5.1 (3.1-7.9) years; 1221 (23%) were followed up for at least 8 years. Overall, 1895 (36%) had BCR, 851 (16%) developed DM, and 242 (5%) died of prostate cancer. PSMA upstage probability was significantly prognostic of all clinical end points, with 8-year C indices of 0.63 (95% CI, 0.61-0.65) for BCR, 0.69 (95% CI, 0.66-0.71) for DM, 0.71 (95% CI, 0.67-0.75) for PCSM, and 0.60 (95% CI, 0.57-0.62) for PCSM (P < .001). The PSMA nomogram outperformed existing risk-stratification tools, except for similar performance to Staging Collaboration for Cancer of the Prostate (STAR-CAP) for PCSM (eg, DM: PSMA, 0.69 [95% CI, 0.66-0.71] vs STAR-CAP, 0.65 [95% CI, 0.62-0.68]; P < .001; Memorial Sloan Kettering Cancer Center nomogram, 0.57 [95% CI, 0.54-0.60]; P < .001; Cancer of the Prostate Risk Assessment groups, 0.53 [95% CI, 0.51-0.56]; P < .001). Results were validated in secondary cohorts from the Surveillance, Epidemiology, and End Results database and the National Cancer Database. Conclusions and Relevance: These findings suggest that PSMA upstage probability is associated with long-term, clinically meaningful end points. Furthermore, PSMA upstaging had superior risk discrimination compared with existing tools. Formerly occult, PSMA PET/CT-detectable nonlocalized disease may be the main driver of outcomes in high-risk patients.

Comparison of Multimodal Therapies and Outcomes Among Patients With High-Risk Prostate Cancer With Adverse Clinicopathologic Features.

Importance: The optimal management strategy for high-risk prostate cancer and additional adverse clinicopathologic features remains unknown. Objective: To compare clinical outcomes among patients with high-risk prostate cancer after definitive treatment. Design, Setting, and Participants: This retrospective cohort study included patients with high-risk prostate cancer (as defined by the National Comprehensive Cancer Network [NCCN]) and at least 1 adverse clinicopathologic feature (defined as any primary Gleason pattern 5 on biopsy, clinical T3b-4 disease, ≥50% cores with biopsy results positive for prostate cancer, or NCCN ≥2 high-risk features) treated between 2000 and 2014 at 16 tertiary centers. Data were analyzed in November 2020. Exposures: Radical prostatectomy (RP), external beam radiotherapy (EBRT) with androgen deprivation therapy (ADT), or EBRT plus brachytherapy boost (BT) with ADT. Guideline-concordant multimodal treatment was defined as RP with appropriate use of multimodal therapy (optimal RP), EBRT with at least 2 years of ADT (optimal EBRT), or EBRT with BT with at least 1 year ADT (optimal EBRT with BT). Main Outcomes and Measures: The primary outcome was prostate cancer-specific mortality; distant metastasis was a secondary outcome. Differences were evaluated using inverse probability of treatment weight-adjusted Fine-Gray competing risk regression models. Results: A total of 6004 men (median [interquartile range] age, 66.4 [60.9-71.8] years) with high-risk prostate cancer were analyzed, including 3175 patients (52.9%) who underwent RP, 1830 patients (30.5%) who underwent EBRT alone, and 999 patients (16.6%) who underwent EBRT with BT. Compared with RP, treatment with EBRT with BT (subdistribution hazard ratio [sHR] 0.78, [95% CI, 0.63-0.97]; P = .03) or with EBRT alone (sHR, 0.70 [95% CI, 0.53-0.92]; P = .01) was associated with significantly improved prostate cancer-specific mortality; there was no difference in prostate cancer-specific mortality between EBRT with BT and EBRT alone (sHR, 0.89 [95% CI, 0.67-1.18]; P = .43). No significant differences in prostate cancer-specific mortality were found across treatment cohorts among 2940 patients who received guideline-concordant multimodality treatment (eg, optimal EBRT alone vs optimal RP: sHR, 0.76 [95% CI, 0.52-1.09]; P = .14). However, treatment with EBRT alone or EBRT with BT was consistently associated with lower rates of distant metastasis compared with treatment with RP (eg, EBRT vs RP: sHR, 0.50 [95% CI, 0.44-0.58]; P < .001). Conclusions and Relevance: These findings suggest that among patients with high-risk prostate cancer and additional unfavorable clinicopathologic features receiving guideline-concordant multimodal therapy, prostate cancer-specific mortality outcomes were equivalent among those treated with RP, EBRT, and EBRT with BT, although distant metastasis outcomes were more favorable among patients treated with EBRT and EBRT with BT. Optimal multimodality treatment is critical for improving outcomes in patients with high-risk prostate cancer.

Single Port Transvesical Robotic Radical Prostatectomy: Initial Clinical Experience and Description of Technique.

OBJECTIVE: To describe our surgical technique and early results for the single port (SP) transvesical robotic radical prostatectomy using the da Vinci SP surgical system. PATIENTS & METHODS: Twenty patients underwent SP radical prostatectomy through a transvesical approach. Through a 3 cm suprapubic incision, the bladder was incised and a GelPOINT mini system was used for floating docking. Through the gel port, the dedicated SP robotic port, a 12 mm assistant port, and a flexible suction tubing were introduced. RESULTS: All cases were completed successfully without need for extra ports or conversion. No intraoperative complications were recorded. Median (IQR) total robotic time was 119 (99-127) minutes. Median (IQR) estimated blood loss was 135 (100-162) mL. Median (IQR) hospital length of stay was 4.4 (3.9-22.2) hours. None of the patients required opioids use after discharge. Median (IQR) time with a Foley catheter after surgery was 4 (4-6) days and 75% of the patients had immediate continence within 48 hours after Foley catheter removal. 85% were totally continent within 10 days after catheter removal. Three patients (15%) had positive surgical margins (all focal) on pathology. Two patients had transvesical lymph node dissection with 4 and 15 lymph nodes negative on final pathology. CONCLUSION: We demonstrated the feasibility of SP robotic transvesical radical prostatectomy and pelvic lymph node dissection using a dedicated SP robotic platform. Favorable perioperative outcomes were seen, along with low complication rate, same day discharge, elimination of opioid requirement, and high rate of immediate recovery of continence as well as a low positive margin rate.

Initial Experience with Single-port Robotic-assisted Kidney Transplantation and Autotransplantation.

BACKGROUND: Compared with the standard open approach, multiport robotic-assisted kidney transplantation (RAKT) has emerged as a less morbid alternative. The use of a single-port robotic approach for kidney transplantation (KT) is presented in this study as having the potential for further reducing the morbidity of KT. OBJECTIVE: To present the technique and evaluate perioperative and short-term (≤1 yr) postoperative outcomes of single-port RAKT. DESIGN, SETTING, AND PARTICIPANTS: Prospective evaluation of peri- and postoperative outcomes in patients who underwent allograft KT (n = 6) or kidney autotransplantation (n = 3). The IDEAL model (www.ideal-collaboration.net/framework) for safe surgical innovation was used. SURGICAL PROCEDURE: Kidney allografts from living or deceased donors were transplanted into six patients with end-stage renal disease. Single-port robotic surgery was performed through a 5-cm midline periumbilical abdominal incision with transperitoneal or extraperitoneal approaches. With similar incision and technique, the right or left kidney was removed and autotransplantation was performed in three patients. MEASUREMENTS: Intra- and postoperative variables, and outcomes were assessed with a descriptive analysis. RESULTS AND LIMITATIONS: Single-port RAKT procedures were completed successfully, with total operative and vascular anastomosis times ranging from 300 to 450 mins and from 52 to 92 mins, respectively. All six patients had excellent graft function with serum creatinine levels at the last follow-up (2 wk to 1 yr), ranging from 1.2 to 1.5 mg/dl. Renal autotransplantation was also completed successfully with a single-port robotic approach in three patients. The total operative and vascular anastomosis times ranged from 510 to 600 mins and from 65 to 83 mins, respectively. In all three cases, serum creatinine levels remained normal after the surgery and during follow-up, and all remained symptom-free at the time of this writing (4-8 mo after their surgeries). CONCLUSIONS: In this initial experience, single-port RAKT is feasible with potential benefits such as offering true single-site minimally invasive surgery, extraperitoneal approach, less morbidity, and comparable short-term graft functional outcomes. PATIENT SUMMARY: We presented the initial experience with the application of single-port robotic surgery for kidney transplantation and autotransplantation. This technique was found to be safe and effective, with promising postoperative outcomes and potentially with less morbidity.

Testicular ultrasound underestimates the size of small testicular masses: a radiologic-pathologic correlation study.

PURPOSE: Increasing use and resolution of testicular ultrasound imaging has resulted in a greater diagnosis of non-palpable small testicular masses and subsequent over-treatment with orchiectomy. Our aim was to determine the diagnostic accuracy of testicular ultrasound to accurately determine the pathologic size of small testicular masses (SMTMs) and to evaluate the association of various measurements with benign pathology. METHODS: Retrospectively, an institutional testicular cancer database was reviewed to evaluate the patients who underwent an orchiectomy for a testicular mass seen on ultrasound from 2003 to 2017. Three-dimensional measurements were compared from the ultrasound and pathology specimens, including other measures such as tumor volume and percentage of testicular volume. Finally, the predictive accuracy of maximum diameter and tumor volume to predict benign pathology was evaluated using receiver-operating curve analysis. RESULTS: We identified 208 patients and showed that ultrasound significantly underestimated sub-centimeter testicular masses (mean difference 0.56 cm, 95%CI 0.89-0.14, p = 0.004) and testicular masses between 1 and < 2 cm (mean difference 0.50 cm, 95%CI 0.97-0.15, p = 0.009). Tumor volume measured on ultrasound was consistently similar to pathologic tumor volume across all sizes and was significantly correlated (Spearman's Rho = 0.81). Mass volume had a greater predictive accuracy for benign pathology than maximum diameter using a 1 cm cut-off (AUC 0.65 vs 0.60). CONCLUSION: Using the maximal diameter, testicular ultrasound significantly miscalculated the pathologic dimensions of masses less than 2 cm compared to orchiectomy specimens. Volumetric measurements may better represent actual tumor sizes for SMTMs and may be a more useful measure for identifying those a higher risk for benign pathology, however, further studies are required.