Robotic-assisted excision of a juxta renal retroperitoneal schwannoma.

Retroperitoneal schwannoma is a rare benign tumor of the peripheral nerve Schwann sheath. We, herein, report the case of a 74-year-old woman who presented with vague abdominal pain. Computed tomography imaging revealed a retroperitoneal mass that is medial to the right kidney. The patient underwent robotic excision of the tumor with the pathology revealing schwannoma. We report this case due to the scarcity of this disease entity, especially at this location and to emphasize the indication and value of robotic technology in different pathological processes retroperitoneally.

Primary infertility secondary to a hidden posterior urethral valve representing a diagnostic challenge in the fifth decade.

Posterior urethral valves (PUVs) are frequently recognized during the perinatal period. Delayed diagnosis is reported usually within the first decade of life with diverse clinical presentations. In the current case report, we describe a 45 years old man patient who presented with aspermia and primary infertility for 8 years in whom his diagnostic workup revealed radiological imaging suggestive of PUVs. This phenomenon was confirmed by cystourethroscopy that showed obstructive valve. Endoscopic ablation resulted in significant improvement of his seminal parameter with successful conception.

Incidental discovery of an interstitial emphysematous cystitis with liver abscess: A report of hematogenous spread of infection.

Emphysematous cystitis is an unusual urological emergency in clinical practice. The disease characteristics are still underreported. It is characterized by the presence of gas in the urinary bladder wall secondary to gas forming organism. We report an incidental finding of emphysematous cystitis in a 35-year-old secondary to a huge liver abscess in a poorly controlled blood sugar. The infection spread hematogenously to the urinary bladder wall that was managed conservatively by urethral catheter drainage and hepatic abscess drainage in adjunct with antimicrobial therapy. The patient had no urinary symptoms. The bladder wall gas disappeared during follow-up in 2 weeks.

Proximal corporal reconstruction: adjunct of penile prosthesis revision surgery.

Proximal corporal deformities may account for failed inflatable penile prosthesis (IPP) surgery. No contemporary series has focused solely on describing the natural history and management of isolated proximal corporal deformities in patients after IPP surgery. The aim of the current report is to present the clinical courses and surgical management with outcomes of proximal corporal deformities in the context of prior IPP implantation surgery. We conducted a retrospective analysis of the Johns Hopkins Hospital institutional database of IPP surgeries from May 2006 to March 2017 consisted of 198 patients who had undergone IPP revisions. All cases involving surgical revisions associated with isolated proximal corporal deformities (proximally from the penoscrotal junction) were identified. Data retrieved included clinical characteristics, operative findings, and surgical outcomes. Main outcome measures are the ability to achieve successful sexual intercourse after IPP revision. The findings of proximal corporal deformities were manifest in fifteen patients who had undergone previous IPP surgery. Deformities consisted of corporal dilatation (15 patients) and corporal rupture (8 patients). Associated prosthesis defects were mechanical failure (2 patients), aneurysmal dilatation (5 patients), and device breakage (4 patients). Median IPP treatment duration was 14 years. Mean number of prior IPP surgeries were 4.2 times. All patients underwent reduction corporoplasty with IPP device replacements consisting of controlled expansion devices. Mean age at revision was 59.7 years. All patients reported successful sexual intercourse and satisfaction within 6 months' follow-up after surgical revision. Proximal corporal deformities arising after IPP surgery are associated with dysfunctional device operation and as well as device defects. Proper recognition of this problem allows the opportunity for surgical correction with a definitive reduction corporoplasty. Failure to recognize these abnormalities timely may predispose to unsuccessful revisions and complicate future definitive surgical repair.

Long-term urinary functional outcome of vesicourethral anastomosis with bidirectional poliglecaprone (Monocryl®) vs. barbed polyglyconate suture (V-LocTM 180) in robot-assisted radical prostatectomy.

INTRODUCTION: We aimed to evaluate urinary continence recovery following robot-assisted radical prostatectomy (RARP) using monofilament poliglecaprone (Monocryl®) suture vs. barbed suture (V-LocTM 180) during vesicourethral anastomosis (VUA). METHODS: In this prospective, observational cohort, data were collected on 322 consecutive patients. All patients underwent continuous, bidirectional, single-layer running anastomosis with either 3.0 monofilament suture (n=141) or 3.0 barbed suture (n=181). The primary outcome was continence recovery defined as time to 0 pad at one, three, six, 12, and 24 months following surgery. RESULTS: Continence rates were significantly better with monofilament VUA at all followup time points up to one year. Median time to continence was one month vs. five months in the monofilament group vs. barbed group, respectively (p<0.001). Continence rates in monofilament suture vs. barbed group at one, three, six, 12, and 24 months were 56% vs. 26% (p<0.001), 73% vs. 36.4% (p<0.001), 84.4% vs. 60.2% (p<0.001), 90.8% vs. 71.9% (p<0.001), and 93.5% vs.87.1% (p=0.1), respectively. Anastomosis time was shorter in the barbed group, with a median of 23 vs. 30 minutes (p<0.001). Patients anastomosed with Monocryl suture had smaller prostate weight (median 42.5 g vs. 50 g; p<0.001) and harbored less advanced disease (T2a-c 76.6 vs. 74%; p=0.01) relative to patients treated with V-Loc 180 suture. However, in a multivariate Cox logistic regression analyses, independent predictors of continence recovery were suture type (hazard ratio [HR] 53; 95% confidence interval [CI] 0.41-0.68; p=0.02] and prostate size (HR 0.99; 95% CI 0.98-0.99; p<0.001). CONCLUSIONS: Barbed VUA contributed to delayed continence recovery compared to monofilament poliglecaprone suture during the first year post-RARP. However, no statistically significant difference was recorded at two years post-RARP. These results warrant special attention, especially with the widespread use of barbed suture in recent years.

Perioperative predictors for post-prostatectomy urinary incontinence in prostate cancer patients following robotic-assisted radical prostatectomy: Long-term results of a Canadian prospective cohort.

INTRODUCTION: We aimed to report the impact of perioperative factors that have not been well-studied on continence recovery following robotic-assisted radical prostatectomy (RARP). METHODS: We analyzed data of 322 men with localized prostate cancer who underwent RARP between October 2006 and May 2015 in a single Canadian centre. All patients were assessed at one, three, six, 12, and 24 months after surgery. We evaluated risk factors for post-prostatectomy urinary incontinence from a prospectively collected database in multivariate Cox regression analysis. The primary endpoint was continence, defined as 0 pad usage per day. RESULTS: 0-pad continence rates were 126/322 (39%), 187/321 (58%), 222/312 (71%), 238/294 (80%), and 233/257 (91%) at one, three, six, 12, and 24 months, respectively. Bladder neck preservation (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.5-0.99; p=0.04), and prostate size (HR 0.99; 95% CI 0.98-0.99; p=0.02) were independent predictors of continence recovery after RARP. Smoking at time of surgery predicted delayed continence recovery on multivariate analysis (HR 1.42; 95% CI 1.01-1.99; p=0.04). Neurovascular bundles preservation was associated with continence recovery after 24 months. No statistically significant correlation was found with other variables, such as age, body mass index, Charlson comorbidity index, preoperative oncological baseline parameters, presence of median lobe, or thermal energy use. CONCLUSIONS: Our results confirmed known predictors of postprostatectomy incontinence (PPI), namely bladder neck resection and large prostate volume. Noteworthy, cigarette smoking at the time of RARP was found to be a possible independent risk factor for PPI. This study is hypothesis-generating.

Penile Wobble Effect: Proximal Corporal Deformities as a Cause of Penile Prosthesis Failure.

INTRODUCTION: Penile structural defects can contribute toward penile prosthesis (PP) surgical complications and suboptimal outcomes. Despite modern improvements in techniques of inflatable PP (IPP) surgeries, suboptimal outcomes arise secondary to unrecognized proximal corporal abnormalities. AIM: To describe a new observation of IPP failure (wobbly penis) secondary to proximal corporal deformities. METHODS: We performed a retrospective analysis of the Johns Hopkins institutional database of patients who had IPP surgery from May 2006 to March 2017. All cases requiring surgical revisions secondary to proximal corporal deformities were identified. Exclusion criteria included patients who had incidentally discovered proximal corporal deformities intraoperatively or were documented preoperatively to have had a corporal defect. MAIN OUTCOME MEASURES: Successful reimplantation of a functionally intact PP device. RESULTS: On clinical grounds, we identified 5 patients with properly cycling but unstable prosthetic devices that were associated with proximal corporal dilatation (proximally from the penoscrotal junction). All patients underwent reduction corporoplasty with prosthesis replacements consisting of controlled expansion IPPs. 3 patients had undergone previous device replacements because of intact cycling but unstable and unusable IPP devices, whereas 2 had a single previous device insertion. Mean age at revision was 67 years. Median IPP duration was 17 years. Median number of previous IPP surgeries was 3. All patients reported IPP stability and satisfaction after revision (median follow-up = 6 months). CONCLUSIONS: Proximal corporal deformities could account for IPP failure. This condition can be under-recognized as observed in the present cases of multiple revisions with a normally cycling device that was not usable. Proper recognition of this problem allows the opportunity for surgical correction with reduction corporoplasty. Rajih E, Burnett AL. Penile Wobble Effect: Proximal Corporal Deformities as a Cause of Penile Prosthesis Failure. Sex Med 2018;6:267-271.

Functional and oncological outcomes of salvage external beam radiotherapy following robot-assisted radical prostatectomy in a Canadian cohort.

INTRODUCTION: We sought to determine the impact of salvage radio-therapy (SRT) on oncological and functional outcomes of patients with prostate cancer after biochemical recurrence (BCR) following robot-assisted radical prostatectomy (RARP). METHODS: Data of 70 patients with prostate cancer treated with SRT after developing BCR were retrospectively analyzed from a prospectively collected RARP database of 740 men. Oncological (prostate-specific antigen [PSA]) and functional (pads/day, International Prostate Symptom Score [IPSS], and Sexual Health Inventory for Men [SHIM]) outcomes were reported at six, 12, and 24 months after RT and adjusted for pre-SRT status. RESULTS: Men who underwent SRT had a mean age, PSA, and time from radical prostatectomy (RP) to RT of 61.8 years (60.1-63.6), 0.5 ng/ml (0.2-0.8), and 458 days (307-747), respectively. Freedom from biochemical failure (FFBF) post-SRT, defined as a PSA nadir <0.2 ng/mL, was observed in 89%, 93%, and 81%, at six, 12, and 24 months, respectively. Undetectable PSA was observed in 14%, 35%, and 40% at the same time points, respectively. There was no significant difference in urinary continence post-SRT (p=0.56). Rate of strict continence (0 pads/day) was 71% at 24 months compared to 78% pre-SRT. Mean IPSS at six, 12, and 24 months was 3.4, 3.6, and 3.6, respectively compared to pre-RT score of 3.3 (p=0.61). The mean SHIM score pre-SRT was comparable at all time points following treatment (p=0.86). CONCLUSIONS: In this unique Canadian experience, it appears that early SRT is highly effective for the treatment of BCR following RARP with little impact on urinary continence and potency outcomes.

Does surgical delay for radical prostatectomy affect biochemical recurrence? A retrospective analysis from a Canadian cohort.

AIM: We sought to explore the impact of surgical wait time (SWT) to robot-assisted radical prostatectomy (RARP) on biochemical recurrence (BCR). METHOD: Retrospective review of a prospectively collected database between 2006 and 2015 was conducted on all RARP cases. SWT was defined as period from prostate biopsy to surgery. Primary outcome was the impact on BCR, which was defined as two consecutive PSA ≥ 0.2 ng/dl, or salvage external beam radiation therapy and/or salvage androgen deprivation therapy. Patients were stratified according to D'Amico risk categories. Univariable analysis (UVA) and multivariable analyses (MVA) with a Cox proportional hazards regression model were used to evaluate the effect of SWT and other predictive factors on BCR, in each D'Amico risk group and on the overall collective sample. RESULTS: Patients eligible for analysis were 619. Mean SWT was 153, 169, 150, and 125 days, for overall, low-, intermediate-, and high-risk patients, respectively. Multivariate analysis on the overall cohort did not show a significant relation between SWT and BCR. On subgroup analysis of D'Amico risk group, SWT was positively correlated to BCR for high-risk group (p = 0.001). On threshold analysis, cut-off was found to be 90 days. SWT did not significantly affect BCR on UVA and MVA in the low- and intermediate-risk groups. CONCLUSION: Increased delay to surgery could affect the BCR, as there was a positive association in high-risk group. Further studies with longer follow-up are necessary to assess the impact of wait time on BCR, cancer specific survival and overall survival.

Does surgical delay for radical prostatectomy affect patient pathological outcome? A retrospective analysis from a Canadian cohort.

INTRODUCTION: We sought to assess the impact of surgical wait time (SWT) to robot-assisted radical prostatectomy (RARP) on final pathological outcome. METHODS: A retrospective review of RARP patient records operated between 2006 and 2015 was conducted. SWT was defined as period from prostate biopsy to surgery. Primary outcome was the impact on postoperative Cancer of the Prostate Risk Assessment (CAPRA-S) score. Patients were stratified according to D'Amico risk categories. Univariate analysis (UVA) and multivariable (MVA) analysis with a generalized linear model was used to evaluate the effect of SWT and other predictive factors on pathological outcome in individual risk group and on the overall sample. RESULTS: A total of 835 patients were eligible for analysis. Mean SWT was significantly different between the three D'Amico groups, with mean SWT of 180.22 days (95% confidence interval [CI] 169.03; 191.41), 159.14 days (95% CI 152.38; 165.90), and 138.96 days (95% CI 124.60; 153.33) for low-, intermediate-, and high-risk groups, respectively (p<0.001). After stratification by D'Amico risk group, no significant association was observed between SWT and CAPRA-S score in the three risk categories on UVA and MVA. Predictors of higher CAPRA-S score in the multivariable model in the overall cohort were: older age (p=0.014), biopsy Gleason score (p<0.001), percentage of positive cores (p<0.001), and clinical stage (p<0.001). CONCLUSIONS: In the present study evaluating SWT for RARP in a Canadian socialized system, increased delay for surgery does not appear to impact the pathological outcome. Further studies are required to evaluate the impact of wait time on biochemical recurrence-free survival, cancer-specific survival, and overall survival.

Error reporting from the da Vinci surgical system in robotic surgery: A Canadian multispecialty experience at a single academic centre.

INTRODUCTION: The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. METHODS: A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. RESULTS: Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. CONCLUSIONS: Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.

Evaluation of Surgical Outcomes with Photoselective GreenLight XPS Laser Vaporization of the Prostate in High Medical Risk Men with Benign Prostatic Enlargement: A Multicenter Study.

OBJECTIVE: To evaluate the safety and short-term outcomes of photoselective vaporization of the prostate (PVP) using GreenLight XPS™ in treatment of high medical risk (HMR) men. METHODS: A multicenter retrospective analysis of 941 men who underwent PVP between August 2010 and August 2014 was performed. Patients were considered HMR if they had an American Society of Anesthesiologists physical status score ≥3. Postoperative adverse events, unexpected postoperative medical provider visits after intervention, and functional urinary outcomes were examined. RESULTS: HMR men (n = 273) were older (mean age 72.3 ± 8.1 years vs 67.1 ± 9 years, p ≤ 0.01), had larger prostate volumes (82.8 ± 48.2 g vs 73.7 ± 49.4 g, p < 0.01), and were more likely to be on anticoagulant and antiplatelet medications (all p ≤ 0.01). Moreover, overall operative time (65 ± 35.1 minutes vs 53.9 ± 24.9 minutes), energy delivered (313.4 ± 207 kJ vs 258 ± 164 kJ), and energy density used (4.2 ± 3.8 kJ/g vs 3.8 ± 3 kJ/g) were greater in the HMR group (all p ≤ 0.05). Although HMR men were more often treated in a hospital setting (p ≤ 0.01), there were no differences in intraoperative adverse events. At 6 months, both groups had notable improvements from baseline for International Prostate Symptom Score, quality of life due to urinary symptoms, maximum urinary flow rate, postvoid residual urine volume, and prostate-specific antigen. Regarding safety, the two groups had comparable 90-day Clavien-Dindo complication rates, numbers of urgent care visits, and numbers of outpatient consultations. HMR men, however, had more hospital readmissions within 90 days postsurgery (3.7% vs 1.3%; p = 0.04). CONCLUSIONS: Despite older age, greater comorbidity, and significant use of anticoagulants, HMR men who undergo photoselective vaporization benefit from symptom improvement and show no clinical difference in adverse event profiles. GreenLight-XPS produces similar short-term outcomes in patients with significant comorbidities when compared with healthy patients.

Safety, Perioperative, and Early Functional Outcomes of Vapor Incision Technique Using the GreenLight XPS 180 W System: Direct Comparison with Photoselective Vaporization of the Prostate.

OBJECTIVES: To compare perioperative parameters, safety, and short-term functional outcomes between GreenLight 180 W-XPS photoselective vaporization of the prostate (PVP) and vapor incision technique (VIT). MATERIALS AND METHODS: A total of 956 men were treated at five high-volume centers in Canada and the United States between 2000 and 2014 for benign prostatic hyperplasia. Perioperative parameters, complications, and early functional outcomes were retrospectively compared. One-to-one propensity score matching was performed to adjust for baseline differences between treatment groups. Subgroup stratified comparative analysis was performed according to preoperative prostate volume 80 cc or less vs greater than 80 cc on transrectal ultrasound (259 and 185 patients, respectively). RESULTS: VIT allowed greater energy delivery and energy density, but operative time and laser time were longer with greater use of MoXy fibers when compared with PVP (all p < 0.05). Improvements in outcomes at 6 months, including International Prostate Symptom Score, quality of life score, and uroflowmetry parameters, were significantly greater after VIT when compared with baseline. VIT was associated with significantly greater 6-month prostate-specific antigen (PSA) reduction (63% vs 50%, p = 0.01). No differences in intraoperative complications were observed between treatment groups. CONCLUSION: VIT is safe and efficacious, providing greater improvements in functional outcomes and PSA reduction at 6 months in comparison with PVP. These results reflect the larger amount of adenoma removed. Yet, it is associated with longer operative time and greater use of MoXy fibers. Long-term follow-up is needed to accurately assess functional outcomes and retreatment rates.

Standardized 4-step technique of bladder neck dissection during robot-assisted radical prostatectomy.

Bladder neck (BN) dissection is considered one of the most challenging steps during robot-assisted radical prostatectomy. Better understanding of the BN anatomy, coupled with a standardized approach may facilitate dissection while minimizing complications. We describe in this article the 4 anatomic spaces during standardized BN dissection, as well other technical maneuvers of managing difficult scenarios including treatment of a large median lobe or patients with previous transurethral resection of the prostate. The first step involves the proper identification of the BN followed by slow horizontal dissection of the first layer (the dorsal venous complex and perivesicle fat). The second step proceeds with reconfirming the location of the BN followed by midline dissection of the second anatomical layer (the anterior bladder muscle and mucosa) using the tip of the monopolar scissor until the catheter is identified. The deflated catheter is then grasped by the assistant to apply upward traction on the prostate from 2 directions along with downward traction on the posterior bladder wall by the tip of the suction instrument. This triangulation allows easier, and safer visual, layer by layer, dissection of the third BN layer (the posterior bladder mucosa and muscle wall). The forth step is next performed by blunt puncture of the fourth layer (the retrotrigonal fascia) aiming to enter into the previously dissected seminal vesical space. Finally, both vas deferens and seminal vesicles are pulled through the open BN and handed to the assistant for upper traction to initiate Denovillier's dissection and prostate pedicle/neurovascular bundle control.

Erectile function recovery after robotic-assisted radical prostatectomy (RARP): long term exhaustive analysis across all preoperative potency categories.

INTRODUCTION: To evaluate erectile function recovery following robotic-assisted radical prostatectomy (RARP) according to preoperative sexual health inventory for men (SHIM) score stratification. MATERIALS AND METHODS: We prospectively collected data on 250 consecutive patients who underwent RARP by a single surgeon between October 2006 and October 2012. Thirty-six patients were excluded because of lack of preoperative SHIM score. All patients had a minimum follow up of 2 years. Patients were divided into four groups according to their preoperative SHIM score: group 1 with normal potency (SHIM 22-25), group 2 with mild ED (SHIM 17-21), group 3 with mild-moderate ED (SHIM 12-16) and group 4 with moderate-severe ED (SHIM 1-11). Patients were followed at 3, 6, 9, 12, 18, 24 months intervals and twice yearly thereafter. SHIM questionnaire and erection hardness scale (EHS) score were collected at each visit. Potency was defined as successful penetration during intercourse (EHS score 3-4) with or without phosphodiesterase type 5-inhibitor (PDE5-I). RESULTS: After exclusion, 214 patients were evaluated. The number of patients in group 1, 2, 3 and 4 were 95, 59, 26 and 34, respectively. At 3, 6, 9, 12, 18, 24 months, SHIM scores and potency rates were statistically different between groups 1 versus 2 versus 3 versus 4 (p < 0.01, at each time point). Patients in each group 1, 2 and 3 showed a statistically significant improvement in potency rates and SHIM scores at consecutive follow up visits up to 24 months (p < 0.01, for each potency group). Potency rates at 24 months for groups 1 to 4 were 83.3%, 54.5%, 50.0%, and 20.7%, respectively (p < 0.001). CONCLUSION: For proper patient counseling and better prediction of erectile function recovery after RARP, it is important to stratify patients according to preoperative SHIM scores. Setting realistic expectations may increase patient satisfaction.

Feasibility of planned mini-laparotomy and adhesiolysis at the time of robotic-assisted radical prostatectomy in patients with prior major abdominal surgery.

INTRODUCTION: Our aim was to report our experience on the feasibility of completing radical prostatectomy robotically after planned open adhesiolysis for prior major abdominal surgery with previous midline laparotomy scar. METHODS: We searched our prospectively collected database of robotic assisted-radical prostatectomy (RARP) performed between October 2006 and October 2012 by a single fellowship-trained surgeon to identify all patients who underwent planned initial mini-laparotomy for release of abdominal adhesions at time of RARP. Among 250 RARP patients, five patients fulfilled these criteria. RESULTS: All patients had prostatectomy completed robotically. The mean values of patients' demographics were as follows: Age 61.8 years (range 54-69), body mass index 30.7 (range 24.3-45.3), and prostate volume 41.5 ml (range 30.8-54). Mean operative time was 245 min (range 190-280) and estimated blood loss 410 ml (range 300-650). Median hospital stay was one day (range 1-7). Postoperatively, there was one prolonged ileus, which resolved spontaneously, and one myocardial infarction. CONCLUSIONS: Robotic completion of radical prostatectomy after open adhesiolysis is feasible. This approach maintains most minimally invasive advantages of RARP, despite a slightly longer hospital stay. In the best interest of patients, robotic surgeons are encouraged to finish the case robotically rather than attempting an open approach.

CAPRA-S predicts outcome for adjuvant and salvage external beam radiotherapy after radical prostatectomy.

INTRODUCTION: We aimed to evaluate the predictive value of the Cancer of the Prostate Risk Assessment Postsurgical Score (CAPRA-S) for patients treated with radical prostatectomy followed by subsequent external beam radiotherapy (EBRT). METHODS: A total of 373 patients treated with EBRT between January 2000 and June 2015 were identified in the institutional database. Followup and complete CAPRA-S score were available for 334 (89.5%) patients. CAPRA-S scores were sorted into previously defined categories of low- (score 0-2), intermediate- (3-5), and high-risk (6-12). Time to biochemical recurrence (BCR) was defined as prostate-specific antigen (PSA) >0.20 ng/mL after EBRT. Survival analyses were performed using the Kaplan-Meier method and comparisons were made using the log-rank test. RESULTS: Overall median time from surgery to EBRT was 18 months (interquartile range [IQR] 8-36) and median followup since EBRT was 48 months (IQR 28-78). CAPRA-S predicted time to BCR (<0.001), time to palliative androgen-deprivation therapy (ADT) (p=0.017), and a trend for significantly predicting overall survival (OS, p=0.058). On multivariate analysis, the CAPRA-S was predictive of time to BCR only (low-risk vs. intermediate-risk; hazard ratio [HR] 0.14, 95% confidence interval [CI] 0.043-0.48, p=0.001). The last PSA measurement before EBRT as a continuous and grouped variable proved highly significant in predicting all outcomes tested, including OS (p≤0.002). CONCLUSIONS: CAPRA-S predicts time to BCR and freedom from palliative ADT, and is borderline significant for OS. Together with the PSA before EBRT, CAPRA-S is a useful, predictive tool. The main limitation of this study is its retrospective design.

Renal artery pseudoaneurysm after robotic-assisted partial nephrectomy: case report.

Renal artery pseudoaneurysm is an uncommonly recognized complication following partial nephrectomy. It is more common with trauma and percutaneous renal intervention. Furthermore, it is rarely reported with minimally invasive laparoscopic partial nephrectomy. Herein, we report the first case to our knowledge of renal artery pseudoaneurysm following a robotic-assisted partial nephrectomy.

Uroflow Stop Test and Potency Recovery: A Surrogate for Pelvic Floor Integrity Post Robotic-Assisted Radical Prostatectomy?

OBJECTIVE: To study the relation between uroflow Stop Test and early recovery of potency following robot-assisted radical prostatectomy (RARP). We recently showed that the ability to completely stop urine flow during voiding, measured objectively by uroflowmetry at the time of catheter removal (uroflow Stop Test) can predict early urinary continence recovery following RARP. MATERIALS AND METHODS: In this prospective observational cohort, data were collected on 108 patients operated by a single surgeon (AEH). Eighty patients had a positive uroflow Stop Test (group one) and 28 had a negative Stop Test (group two). Patients were followed for a minimum of 2 years. Covariates included age, body mass index, international prostate symptom score and sexual health inventory for men scores, prostate-specific antigen, tumor stage, prostate volume, nerve sparing status, and estimated blood loss. RESULTS: Preoperative characteristics were comparable between both groups except nerve sparing and prostate-specific antigen which were statistically higher in group one (P <.05). Early 3- and 6-months recovery of erectile function was significantly higher in group one. Potency rates in group one and two at 1, 3, 6, 9, 12, 18, and 24 months were 25% vs 14.3% (P = .241), 54.5% vs 18.5% (P = .001), 55.4% vs 18.5% (P = .001), 56.4% vs 36% (P = .084), 66.6% vs 50% (P = .141), 65.5% vs 56% (P = .404) and 73.2% vs 57.7% (P = .160) respectively. Uroflow Stop Test was independent predictor of early potency recovery on multivariate regression analysis at 6 months [odds ratio 6.042 (confidence interval 95% 1.496-24.413) P = .012]. CONCLUSION: Uroflow Stop Test is simple and can help predict early potency recovery following RARP.

Robotic transmesocolonic Pyelolithotomy of horseshoe kidney.

INTRODUCTION: The purpose of this video is to demonstrate the use of the robot to perform a transmesocolonic pyelolithotomy of a horseshoe kidney. MATERIALS AND METHODS: A 35-year old female presented with vague abdominal pain. CT scan imaging revealed the presence of a left horseshoe kidney with multiple pelvicalyceal stones. The patient was positioned in the supine position. A total of 4 ports were introduced. A 3-arm da Vinci robotic surgical system was docked, and the arms were connected. First, the dilated renal pelvis was identified behind the thin mesocolon. The mesocolon was entered and renal pelvis was dissected completely from the surrounding fat. Then, the renal pelvis was opened after adequate dissection and stones were visualized inside the calyces. By Prograsp forceps, stones were removed from all the calyces under vision and were extracted from the assistant trocar. Finally, the pylotomy incision was closed using 4 0 Maxon in a continuous fashion and the mesocolon was closed using 3 0 PDS interrupted sutures. A JP drain was placed. RESULT: Operative time was forty-five minutes, blood loss was 100 ml. The patient was discharged after 48 hours with no immediate complications. CONCLUSION: The utilization of minimal invasive surgery using the robot to extract multiple pelvicalyceal stones from a horseshoe kidney without reflecting the mesocolon proved to be a feasible and novel way in the management of complex stone disease improving the outcome with minimal morbidity.