Minimally invasive cytoreductive radical prostatectomy, exploring the safety and feasibility of a single-port or multi-port robotic platform.

BACKGROUND: Consolidative resection or cytoreductive radical prostatectomy (CRP) may benefit men with non-organ confined prostate cancer. We report the safety, feasibility, and outcomes of robot-assisted laparoscopic CRP using a single-port (SP) or multi-port (MP) platform. METHODS: We reviewed consecutive men with clinical node positive or metastatic castrate-sensitive prostate cancer who underwent IRB-approved CRP and extended pelvic lymph node dissection using the da Vinci SP or MP Surgical Systems (Intuitive Surgical, Sunnyvale, CA) from 2015-2022. Perioperative data and Clavien-Dindo 90-day complications were recorded. RESULTS: Twenty-four men with a median age of 61 (IQR 56-69) years and prostate-specific antigen of 32.1 (IQR 21.9-62.3) ng/mL were included. Clinical N1, M1, or N1 + M1 disease were detected in 8 (33%), 9 (38%), 7 (29%) patients, respectively. There was no difference in positive margins, 41% vs. 29% (P = 0.67), lymph node yield, 21 (IQR 14-28) vs. 20 (IQR 13.5-21) nodes (P = 0.31), or estimated blood loss, 150 mL (IQR 100-200) vs. 50 mL (IQR 50-125) (P = 0.06), between the MP and SP cohorts, respectively. Hospital length of stay was significantly shorter for the SP group, same-day discharge (IQR 0-0), compared to MP, 1-day (IQR 1-1), P < 0.001. One grade III bowel obstruction and lymphocele occurred in the MP cohort. No major complications occurred in the SP cohort. CONCLUSION: Robot-assisted laparoscopic CRP is safe and feasible for select men with advanced castrate-sensitive prostate cancer.

Effect of stone composition on surgical stone recurrence: single center longitudinal analysis.

INTRODUCTION The objective of this study is to explore the association between urinary stone composition and surgical recurrence. MATERIALS AND METHODS: Patients who underwent kidney stone surgeries (between 2009-2017), were followed for > 1 year, and had ≥ 1 stone composition analyses were included in our analysis. Surgical stone recurrence (repeat surgery) was defined as the second surgery on the same kidney unit. Recurrence-free survival analysis was used. RESULTS: A total number of 1051 patients were included (52.7% men, average age 59.1 +/- 15.1 years). Over 4.7 +/- 2.5 years follow up, 26.7% of patients required repeat surgery. Patients' stone compositions were calcium oxalate (66.0%), uric acid (12.2%), struvite (10.0%), brushite (5.7%), apatite (5.1%) and cystine (1.0%). Results suggested that patients with cystine stones had the highest surgical recurrence risk; brushite had the second-highest surgical recurrence risk. Struvite, uric acid, and apatite stones were at higher risk compared with calcium oxalate stones (lowest risk in our cohort). When pre and postoperative stone size was controlled, patients with a history of uric acid, brushite, and cystine stones were at higher surgical risk. After controlling clinical and demographic factors, only brushite and cystine stones were associated with higher surgical recurrence. CONCLUSIONS: Patients with cystine stones had the highest surgical recurrence risk; brushite stones had the second highest surgical recurrence risk. Struvite, uric acid, and apatite stones were at higher risk compared with calcium oxalate stones. When pre and postoperative stone size, clinical and demographic factors were controlled, only those with brushite or cystine stones were at significantly higher risk of surgical recurrence.

Minimally Invasive Hernia Repair in Robot-assisted Radical Prostatectomy.

Inguinal hernia is a recognized complication of radical prostatectomy. Previous hernia repair, wound infection, midline incision, low BMI, and preexisting or subclinical hernia contribute to the risk of inguinal hernia following radical prostatectomy. Concomitant hernia repair at the time of pelvic surgery has risks and benefits. Repair during surgery prevents future hernia-related complications and saves the need for an additional procedure. However, hernia repair at the time of radical prostatectomy includes the risk of mesh infection, post-operative pain, adhesions, lack of experience, and overall minimal risk with watchful waiting. The robotic transperitoneal approach is the most commonly used technique for concomitant inguinal hernia repair with a modest addition to operative time and minimal postoperative complications. Recurrence rates following concomitant hernia repair during pelvic surgery are low.

Pathological characteristics and prognostic indicators of different histopathological types of urinary bladder cancer following radical cystectomy in a large single-center Egyptian cohort.

OBJECTIVE: To evaluate differences in pathological features and prognostics across four bladder cancer histopathological types: urothelial carcinoma (UC), urothelial carcinoma with variant histology (UCV), squamous cell carcinoma (SCC) and adenocarcinoma (ADC), utilizing a large cohort of radical cystectomy (RC) patients. METHODS: A retrospective analysis of patients who underwent RC at a single institution in Egypt between 1997 and 2004 was performed. Kaplan-Meier and multivariable analyses were performed to evaluate the prognostic significance of pathological features including tumor stage, grade, lymphovascular invasion (LVI), and lymph node (LN) involvement in the different subtypes on disease-free survival (DFS). RESULTS: 1238 patients (975 male, 263 female) were included, of whom 577 (47%) had UC, 174 (14%) UCV, 398 (32%) SCC, and 89 (7%) ADC. Median age was 54 (20-87) years and median follow-up was 40 months (0-110). There were significant differences in stage, grade, LVI, LN involvement, and presence of schistosomiasis across the subtypes (all p < 0.05). The prognostic significance of LVI was more evident in SCC (HR 2.14, p = 0.003) and ADC (HR 2.17, p = 0.044) than in UC (HR 1.66, p = 0.008). LN involvement was the strongest prognostic factor in UCV (HR 2.14, p = 0.012). CONCLUSIONS: There are significant differences in clinicopathological features and their prognostic impact across bladder cancer subtypes. The prognostic significance of LVI is more evident in SCC and ADC, while LN involvement is more prognostic in UCV. Determining independent predictors in individual subtypes can guide multimodal treatment selection and clinical trial design.

Skin-to-tumor Distance Predicts Treatment Failure of T1A Renal Cell Carcinoma Following Percutaneous Cryoablation.

OBJECTIVE: To determine the impact of skin-to-tumor (STT) distance on the risk for treatment failure following percutaneous cryoablation (PCA). METHODS: We retrospectively reviewed patients who underwent PCA with documented T1a recurrent renal cell carcinoma (RCC) at 2 academic centers between 2005 and 2015. Patient demographics, tumor characteristics, and perioperative and postoperative course variables were collected. Additionally, we measured the STT distance by averaging the distance from the skin to the center of the tumor at 0°, 45°, and 90° on preoperative computed tomography imaging. RESULTS: We identified 86 patients with documented T1a RCC. The mean age at the time of surgery was 69 years (range: 37-91 years), and the mean tumor size was 2.7 cm (range: 1.0-4.0 cm). With a mean follow-up of 24 months (range: 3-63 months), 11 (12.8%) treatment failures occurred. Patients with treatment failure had significantly higher mean STT distance than those without: 11.0 cm (range: 6.3-20.1 cm) compared to 8.4 cm (range: 4.4-15.2 cm), respectively (P = .002). STT distance was an independent predictor of treatment failure (odds ratio: 1.32, 95% confidence interval: 1.04-1.69, P = .029). STT distance greater than 10 cm had a fourfold increased risk of tumor treatment failure (odds ratio: 4.43, 95% confidence interval: 1.19-16.39, P = .018). Tumor size, R.E.N.A.L. Nephrometry score, and number of cryoprobes placed were not associated with treatment failure. CONCLUSION: STT, an easily measured preoperative variable, may inform the risk of RCC treatment failure following PCA.

C-SATS: Assessing Surgical Skills Among Urology Residency Applicants.

BACKGROUND: We hypothesized that surgical skills assessment could aid in the selection process of medical student applicants to a surgical program. Recently, crowdsourcing has been shown to provide an accurate assessment of surgical skills at all levels of training. We compared expert and crowd assessment of surgical tasks performed by resident applicants during their interview day at the urology program at the University of California, Irvine. MATERIALS AND METHODS: Twenty-five resident interviewees performed four tasks: open square knot tying, laparoscopic peg transfer, robotic suturing, and skill task 8 on the LAP Mentor™ (Simbionix Ltd., Lod, Israel). Faculty experts and crowd workers (Crowd-Sourced Assessment of Technical Skills [C-SATS], Seattle, WA) assessed recorded performances using the Objective Structured Assessment of Technical Skills (OSATS), Global Evaluative Assessment of Robotic Skills (GEARS), and the Global Operative Assessment of Laparoscopic Skills (GOALS) validated assessment tools. RESULTS: Overall, 3938 crowd assessments were obtained for the four tasks in less than 3.5 hours, whereas the average time to receive 150 expert assessments was 22 days. Inter-rater agreement between expert and crowd assessment scores was 0.62 for open knot tying, 0.92 for laparoscopic peg transfer, and 0.86 for robotic suturing. Agreement between applicant rank on skill task 8 on the LAP Mentor assessment and crowd assessment was 0.32. The crowd match rank based solely on skills performance did not compare well with the final faculty match rank list (0.46); however, none of the bottom five crowd-rated applicants appeared in the top five expert-rated applicants and none of the top five crowd-rated applicants appeared in the bottom five expert-rated applicants. CONCLUSIONS: Crowd-source assessment of resident applicant surgical skills has good inter-rater agreement with expert physician raters but not with a computer-based objective motion metrics software assessment. Overall applicant rank was affected to some degree by the crowd performance rating.

Minimally Invasive Hernia Repair in Robot-Assisted Radical Prostatectomy.

Inguinal hernia is a recognized complication of radical prostatectomy. Previous hernia repair, wound infection, midline incision, low body mass index, and preexisting or subclinical hernia contribute to the risk of inguinal hernia after radical prostatectomy. Concomitant hernia repair at the time of pelvic surgery has risks and benefits. Repair during surgery prevents future hernia-related complications and saves the need for an additional procedure. However, hernia repair at the time of radical prostatectomy includes the risk of mesh infection, postoperative pain, adhesions, lack of experience, and overall minimal risk with watchful waiting. The robotic transperitoneal approach is the most commonly used technique for concomitant inguinal hernia repair with a modest addition to operative time and minimal postoperative complications. Recurrence rates after concomitant hernia repair during pelvic surgery are low.

Effect of tumor location on survival in urinary bladder adenocarcinoma: A population-based analysis.

PURPOSE: To investigate the prognostic significance of tumor location on survival outcomes in patients with urinary bladder adenocarcinoma (BAC). METHODS: We retrospectively analyzed cases of BAC with known tumor location from the Surveillance, Epidemiology, and End Results database from 1973 to 2012. Data regarding patient demographics, tumor characteristics, and oncological and survival outcomes were collected. Patients were subgrouped according to tumor location into urachal/dome (dome and urachus [UD]), lateral wall (anterior, posterior, and lateral bladder walls [LW]), and base (trigone, ureteral orifices, and bladder neck [BL]). RESULTS: A total of 1,361 cases of BAC with known tumor location were identified. More UD tumors were low grade (grade I and II; 51%) than LW (33%) and BL (43%) tumors (P<0.0001). UD lesions were the most likely to have metastatic spread (23% vs. 17% for LW and 15% for BL) (P<0.0001). The 5-year overall survival (OS) and disease-specific survival (DSS) rates were 37.3% and 49.0%, respectively, for all BAC. Furthermore, the 5-year OS rates were 42.3%, 35.9%, and 28.4% for UD, LW, and BL lesions, respectively (P<0.0001), whereas the 5-year DSS rates were 50.2%, 51.7%, and 42.1% for UD, LW, and BL lesions, respectively (P = 0.0097). Multivariate Cox regression analysis controlling for tumor stage and grade demonstrated that both tumors of the LW (hazards ratio [HR] = 1.52 for OS and 1.30 for DSS) and BL (HR = 1.71 for OS and 1.57 for DSS) conferred a worse prognosis relative to those of the UD (P< 0.05). CONCLUSIONS: Tumor location of BAC is an independent prognostic factor for disease outcome. Our results suggest that the urachal and dome locations are associated with relatively favorable survival and oncological outcomes, whereas basal location confers poorer outcomes.

Cost Comparisons Between Different Techniques of Percutaneous Renal Biopsy for Small Renal Masses.

PURPOSE: To compare the costs associated with ultrasound (US)-guided hospital-based (UGHB), CT-guided hospital-based (CTG), and US-guided office-based (UGOB) percutaneous renal biopsy (PRB) for small renal masses (SRMs). METHODS: We retrospectively analyzed patient demographics, tumor characteristics, R.E.N.A.L. nephrometry scores, and cost data of patients undergoing PRB for SRM at our institution from May 2012 to September 2015. Cost data, including facility costs, professional fees, and pathology, were obtained from the departments of urology, radiology, and pathology. RESULTS: A total of 78 patients were included in our analysis: 19, 31, and 28 UGHB, CTG, and UGOB, respectively. There was no difference in age, gender distribution, or tumor size among the three groups (p-values 0.131, 0.241, and 0.603, respectively). UGOB tumors had lower R.E.N.A.L. nephrometry scores (p=0.008). There were no differences in nondiagnostic rates between the UGHB, CTG, and UGOB groups [4 (21%), 5 (16%), and 6 (21%)] (p=0.852). There were no differences in final tumor treatment strategies utilized among the UGHB, CTG, and UGOB groups (p=0.447). There were 0, 2 (6%), and 0 complications in the UGHB, CTG, and UGOB biopsy groups. Total facility costs were $3449, $3280, and $1056 for UGHB, CTG, and UGOB PRB, respectively (p<0.0001). There was no difference between the urologist's and radiologist's professional fees (p=0.066). Total costs, including facility costs, pathology fees, and professional fees, were $4598, $4470, and $2129 for UGHB, CTG, and UGOB renal biopsy, respectively (p<0.0001). CONCLUSION: For select patients with less anatomically complex, exophytic, and posteriorly located tumors, UGOB PRB provides equivalent diagnostic and complication rates while being significantly more cost-effective than either UGHB or CTG renal biopsy.