A Comprehensive Review of the Current State of Robot-assisted Laparoscopic Salvage Prostatectomy.

BACKGROUND AND OBJECTIVE: Salvage robot assisted radical prostatectomy (sRARP) is performed for patients with biochemical or biopsy proven, localized prostate cancer recurrences after radiation or ablative therapies. Traditionally, sRARP has been avoided by lower volume surgeons due to technical demand and high complication rates. Post-radiation sRARP outcomes studies exist but remain few in number. With increasing use of whole gland and focal ablative therapies, updates on sRARP in this setting are needed. The aim of this narrative review is to provide an overview of recently reviewed studies on the oncologic outcomes, functional outcomes, and complications after post-radiation and post-ablative sRARP. Tips and tricks are provided to guide surgeons who may perform sRARP. MATERIALS AND METHODS: We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010-2022 without limitation on study design. Only case reports, editorial comments, letters, and manuscripts in non-English languages were excluded. Key Content and Findings: Salvage robotic radical prostatectomy is performed in cases of biochemical recurrence after radiation or ablative therapies. Oncologic outcomes after sRARP are worse compared to primary surgery (pRARP) though improvements have been made with the robotic approach when compared to open salvage prostatectomy. Higher pre-sRARP PSA levels and more advanced pathologic stage portend worse oncologic outcomes. Patients meeting low-risk, EAU-biochemical recurrence criteria have improved oncologic outcomes compared to those with high-risk BCR. While complication rates in sRARP are higher compared to pRARP, Retzius sparing approaches may reduce complication rates, particularly rectal injuries. In comparison to the traditional open approach, sRARP is associated with a lower rate of bladder neck contracture. In terms of functional outcomes, potency rates after sRARP are poor and continence rates are low, though Retzius sparing approaches demonstrate acceptable recovery of urinary continence by 1 year, post-operatively. CONCLUSIONS: Advances in the robotic platform and improvement in robotic experience have resulted in acceptable complication rates after sRARP. However, oncologic and functional outcomes after sRARP in both the post-radiation and post-ablation settings are worse compared to pRARP. Thus, when engaging in shared decision making with patients regarding the initial management of localized prostate cancer, patients should be educated regarding oncologic and functional outcomes and complications in the case of biochemically recurrent prostate cancer that may require sRARP.

Safety and complications of continuation of aspirin therapy in patients undergoing robot-assisted laparoscopic simple prostatectomy.

To evaluate the safety and feasibility of continued perioperative aspirin at the time of robotic assisted simple prostatectomy (RASP). We performed a retrospective review of our IRB approved institutional database of patients who underwent RASP between 2013 and 2022. Comparative groups included patients taking aspirin in the perioperative period and those not taking aspirin pre-operatively. The primary outcome was any post-operative bleeding related complication using the modified Clavien-Dindo classification. Secondary outcomes included the identification of risk factors for increased blood loss in the entire study population, operative time, and blood transfusion requirement. 143 patients underwent RASP of which 55 (38.5%) patients continued perioperative aspirin therapy and 88 (61.5%) patients did not. Baseline demographics were similar between groups. Patients taking perioperative aspirin had a higher rate of hypertension (74.5% vs 58.0%, p = 0.04) and other cardiovascular disease (30.9% vs 11.4%, p = 0.007). Postoperative complications were similar between the groups (Clavien-Dindo ≥ 3; p = 0.43). Median blood loss (150 cc vs 150 cc, p = 0.38), percentage drop in hemoglobin (13.4 vs 13.2, p = 0.94) and blood transfusion rate (3.6 vs 1.1, p = 0.56) were also similar between groups. The median blood loss was 150 ml for the whole study population. On regression analysis, neither aspirin nor any other variable was associated with increased blood loss (> 150 ml). Aspirin can be safely continued perioperatively in patients undergoing RASP without any risk of bleeding related complications, blood loss, or increased transfusion rate.

Surgeon-administered regional nerve blocks during radical cystectomy: a feasibility study.

OBJECTIVE: To describe the technique for surgeon-administered, ultrasound-guided transversus abdominis plane (SU-TAP) blocks performed during radical cystectomy as a component of multimodal, perioperative pain management. METHODS: Retrospective, case series of patients receiving SU-TAP blocks just prior to incision for RC. TAP blocks were performed by the surgeon with a standard technique using US guidance to instill an anesthetic solution. The primary outcome was opioid consumption at the intervals of 0-12, 12-24, 24-36, and 36-48 h postoperatively. Opioid consumption was reported as oral morphine milligram equivalents (MME). Secondary outcomes included time to perform SU-TAP blocks, and safety of block procedure. RESULTS: 34 patients were included. During the median length of stay of 4 days (interquartile range [IQR] 3-7), only 30/34 (88%) of patients required opioids within the first 12 h post-op, decreasing to 38% by 48 h post-op. The median consumption decreased in the first 48 h from 21 MMEs (IQR 9-38) to 10 MMEs (IQR 8-15) at the 0-12 and 36-48 h intervals, respectively. The median time to perform block procedure was 6 min (IQR 4-8 min) and there were no safety events related to the SU-TAP blocks. Limitations include no comparative arm for opioid consumption. CONCLUSION: Our data suggest that urologists may feasibly perform US-guided TAP blocks as a practical, efficient, and safe method of regional anesthesia. SU-TAP blocks should be considered in ERAS protocols for RC. Future comparative studies on opioid consumption compared to local infiltration and alternative block techniques are warranted.

Ileal Conduit versus Cutaneous Ureterostomy after Open Radical Cystectomy: Comparison of 90-Day Morbidity and Tube Dependence at Intermediate Term Follow-Up.

Background: This study aims to compare perioperative morbidity and drainage tube dependence following open radical cystectomy (ORC) with ileal conduit (IC) or cutaneous ureterostomy (CU) for bladder cancer. Methods: A single-center, retrospective cohort study of patients undergoing ORC with IC or CU urinary diversion between 2020 and 2023 was carried out. The 90-day perioperative morbidity, as per Clavien-Dindo (C.D.) complication rates (Minor C.D. I-II, Major C.D. III-V), and urinary drainage tube dependence (ureteral stent or nephrostomy tube) after tube-free trial were assessed. Results: The study included 56 patients (IC: 26, CU: 30) with a 14-month median follow-up. At 90 days after IC or CU, the frequencies of any, minor, and major C.D. complications were similar (any-69% vs. 77%; minor-61% vs. 73%; major-46% vs. 30%, respectively, p > 0.2). Tube-free trial was performed in 86% of patients with similar rates of tube replacement (19% IC vs. 32% CU, p = 0.34) and tube-free survival at 12 months was assessed (76% IC vs. 70% CU, p = 0.31). Conclusions: Compared to the ORC+IC, ORC+CU has similar rates of both 90-day perioperative complications and 12-month tube-free dependence. CU should be offered to select patients as an alternative to IC urinary diversion after RC.

Urothelial Carcinoma Recurrence With an Ileal Conduit: Multimodal Management With Extirpative Surgery, Chemotherapy, and Immunotherapy.

Ileal conduit (IC) is the most performed urinary diversion after radical cystectomy (RC) for urothelial carcinoma (UC) of the bladder. While UC recurrence after RC is well-described, recurrence of UC within a urinary diversion is much less prevalent, and thus, management of these lesions is not well understood. Here, we report the case of a 59-year-old male with a history of invasive UC with glandular differentiation of the urinary bladder who had carcinoma in situ recurrence after induction, intravesical Bacille Calmette-Guerin therapy. He underwent robot-assisted laparoscopic radical cystoprostatectomy (RALC) with bilateral pelvic lymph node dissection and intracorporal ileal conduit (IC) urinary diversion. Two years later, he presented to the emergency department with hematuria. Computed tomography demonstrated a mass within the IC. He subsequently underwent IC resection and ligation of bilateral ureters and had permanent nephrostomy tubes placed, with the final pathology confirming high-grade UC. Positron emission tomography revealed hypermetabolic soft tissue implants within the greater omentum and retroperitoneum for which he underwent fine-needle aspiration, demonstrating recurrence of poorly differentiated UC. Ultimately, the patient started treatment with systemic gemcitabine and carboplatin and completed 4 cycles before transitioning to maintenance avelumab therapy. No disease progression was noted at 16 months post-treatment. Herein, we present a review of the literature and our management of the present patient.

Comparative outcomes and cost of ambulatory PCNL in select kidney stone patients.

Limited hospital resources and access to care during the COVID-19 pandemic led us to implement a quality-improvement study investigating the feasibility, safety, and costs of same-day discharge after PCNL. The outcomes of 53 consecutive first-look PCNL patients included in a same-day discharge protocol during COVID-19 were compared to 54 first-look PCNL patients admitted for overnight observation. Control group had a similar comorbidity profile. Demographics, operative details, 30 day outcomes and readmissions, complications, and cost were compared between the two groups. Same-day discharge and one-day admission post-PCNL patients did not have significantly different baseline characteristics. The study group were more likely to have mini-PCNL (81% vs 50%, p < 0.01). Operative characteristics including median pre-operative stone burden (1.4 vs 1.7 cm3, p = 0.47) and post-operative stone burden (0.14 vs 0.18 cm3, p = 0.061) were similar between the two groups. Clavien-Dindo complication rates were lower in the study group compared to controls (0 vs 7%, p = 0.045). Readmission rates (2 vs 4%, p = 0.569) and ED visits (4 vs 6%, p = 0.662) were similar between the two groups. Total cost ($6,648.92 vs $9,466.07, p < 0.01) was significantly lower and operating margin ($4,475.96 vs $1,742.16, p < 0.01) was significantly higher for the same-day discharge group. Percutaneous nephrolithotomy may be performed in select patients without an increase in short-term complications, ED visits, or readmissions. Patients undergoing mini-PCNL are particularly amenable to same-day discharge, however, standard PCNL patients should not be excluded from consideration. Avoiding overnight admission decreases total cost and increased hospital operating margin.

A Modified Endoscopic Primary Realignment of Severe Bulbar Urethral Injury.

Purpose: Male urethral injury is a common urologic emergency in developing countries. Whether early or late treatment of urethral injuries is often multifactorial and controversial. The goal of this study is to determine whether early realignment can reduce postsurgical complications and evaluate the clinical feasibility of emergency endoscopic urethroplasty using single rigid ureteroscopy in the treatment of bulbar urethral severe injury. Patients and Methods: Between September 2013 and March 2019, 15 male adult patients (mean age 35 years; from 21 to 62 years) with severe bulbar urethral injury were enrolled into the current study. The patients mainly presented with dysuria or painful urination (15/15, 100%), urethral bleeding (13/15, 86.7%), and urinary retention (11/15, 73.3%). Six of them had swelling of perineal or scrotal soft tissue, while four had testicular contusion. No pelvic fracture was found in all cases with CT scanning of the pelvic cavity. The bulbar urethral at grade IV was confirmed to be completely ruptured in all cases by endoscopy during operation. The modified endoscopic primary realignment was performed. Results: This new urethral repair technique was effectively performed in all patients and none converted to open operation. Mean operation time was 42.3 ± 11.5 minutes (28-52 minutes) and the mean Foley catheter indwelling time was 34.5 ± 6.9 days (28-42 days). During a follow-up of 41.3 ± 22.8 months (12-64 months), mild urethral strictures (grade I) (19.7 ± 9.5 weeks, 10-27 weeks postsurgery) developed in 8 patients (53.3%) and then were all improved 2.1 ± 0.8 months (1.3-2.9 months) after periodic dilatations of the urethra (4-10 times). Erectile dysfunction (ED) occurred in three patients (20%) after surgery, who recovered from mild ED to normal by administration with oral sildenafil (100 mg, three times a week) for 12 weeks. The International Index of Erectile Function-5 (IIEF-5) score was significantly improved after surgery (M ± SD, 25 ± 3) compared with before (16.4 ± 3.5) (p < 0.05). No incontinence and other complications occurred in all cases. Conclusions: Early endoscopic realignment via suprapubic puncture cystostomy by single rigid ureteroscopy provides an effective, feasible, and safe procedure for severe bulbar urethral injury.

Sustained Glycemic Control Observed in Diabetic Men Who Improve Hemoglobin A1c Values to Allow for Elective Penile Prosthesis Placement.

OBJECTIVES: We hypothesize that men with diabetes mellitus whose inflatable penile prosthesis (IPP) implantation is delayed for unacceptably high hemoglobin A1c (HbA1c) will have durable improvements in their glycemic control after achieving acceptable HbA1c levels for surgery. METHODS: Per institutional protocol, an A1c <9% must be documented prior to IPP placement. After IRB approval, a single surgeon IPP database was retrospectively queried for data specific to diabetes mellitus management. Men without HbA1c values at ≥1-year follow-up were excluded. Univariate and multivariate statistical analyses were performed to assess associations with sustained HbA1c control. RESULTS: From January 2011 to March 2019, 138 diabetics undergoing IPP were identified. Thirty-seven were excluding for insufficient follow-up. Nineteen of the 101 analyzed men (18.8%) were delayed a median 4 months (range 2-17) for elevated HbA1c values (median 10.1, range 9.1-12.3). Following improvements, median preoperative HbA1c remained higher (8.2% vs 7.0%) in delayed men (P < .001). Among delayed recipients, 11 (58%) improved without medication changes while insulin was newly initiated (5) or dosage was increased (5) in 42%. At 32 months follow-up, a HbA1c <9% was similarly maintained in delayed and nondelayed men (74% vs 87%, P = .17). Delayed men more commonly required insulin therapy at follow-up (89.5% vs 54.9%, P = .008), but had a similar median change in BMI (+0.1 vs +0.1, P = .65). Device infection occurred in 1 nondelayed patient (0.7%). CONCLUSION: Men who improve HbA1c for IPP surgery are likely to demonstrate persistent improvement. IPP implantation appears to be safe in diabetic men with HbA1c <9%.

Hip Joint Pathology Among Men Referred to Urology for Chronic Orchialgia: A Source for Misdiagnosis and Opportunity for Quality Improvement.

OBJECTIVE: To evaluate the findings of magnetic resonance imaging (MRI) of the ipsilateral hip(s) as part of the workup of men with chronic orchialgia (CO). METHODS: Following IRB approval, a retrospective chart review was performed from a single surgeon database of all men with a diagnosis of CO from June 2018 to October 2019 who underwent subsequent hip MRI evaluation. RESULTS: Ten men were identified. Median age was 51 years and median duration of pain was 10 months. MRI was obtained after testis pathology was ruled out. Pain was noted in the groin (100%) and hip (50%). Hip MRI identified overt labral tears in 8 men (10/12 hips evaluated, 83%) and labral fraying in the remaining 2 (16.7%). Standard plain film radiography was performed in 6 men prior to MRI, all of which were negative. Following MRI, 5 men underwent hip injection with steroid and local analgesic with lasting resolution (2 men) or significant improvement in pain (2 men; 80%, follow-up 3-15 months). Two men had complete resolution of pain with 8 weeks of physical therapy. CONCLUSION: Hip MRI has a high rate of diagnosis of labral tear in appropriately selected men referred to the urologist for CO. Identification of orthopedic pathology may avoid unnecessary antibiotics, opiates, or urological surgery. Referrals to orthopedics and/or physical therapy for intervention may lead to resolution of pain.

Dynamic Changes in Erectile Function and Histological Architecture After Intracorporal Injection of Human Placental Stem Cells in a Pelvic Neurovascular Injury Rat Model.

INTRODUCTION: The human placenta provides a bountiful and noncontroversial source of stem cells which have the potential for regeneration of injured tissue. These cells may restore erectile function after neurovascular tissue injury such as that seen in radical pelvic surgeries and pelvic trauma. AIM: To determine the effect of human placenta-derived stem cells on erectile function recovery and histological changes at various time points in a cavernous nerve injury rat model and to study the fate of injected stem cells throughout the regenerative process. METHODS: Human placental stem cells (PSCs) were dual labeled with monomeric Katushka far red fluorescent protein (mKATE)-renLUC using a lentivirus vector. A pelvic neurovascular injury-induced erectile dysfunction model was established in male, athymic rats by crushing the cavernous nerves and ligating the internal pudendal neurovascular bundles, bilaterally. At the time of defect creation, nonlabeled PSCs were injected into the corpus cavernosum at a concentration of 2.5 × 106 cells/0.2 mL. The phosphate-buffered saline-treated group served as the negative control group, and age-matched rats (age-matched controls) were used as the control group. Erectile function, histomorphological analyses, and Western blot were assessed at 1, 6, and 12 weeks after model creation. The distribution of implanted, dual-labeled PSCs was monitored using an in vivo imaging system (IVIS). Implanted cells were further tracked by detection of mKATE fluorescence in histological sections. MAIN OUTCOME MEASURE: The main outcome measure includes intracavernous pressure/mean arterial pressure ratio, neural, endothelial, smooth muscle cell regeneration, mKATE fluorescence, and IVIS imaging. RESULTS: The ratio of intracavernous pressure to mean arterial pressure significantly increased in PSC-injected rats compared with phosphate-buffered saline controls (P < 0.05) at the 6- and 12-week time points, reaching 72% and 68% of the age-matched control group, respectively. Immunofluorescence staining and Western blot analysis showed significant increases in markers of neurons (84.3%), endothelial cells (70.2%), and smooth muscle cells (70.3%) by 6 weeks in treatment groups compared with negative controls. These results were maintained through 12 weeks. IVIS analysis showed luminescence of implanted PSCs in the injected corpora immediately after injection and migration of cells to the sites of injury, including the incision site and periprostatic vasculature by day 1. mKATE fluorescence data revealed the presence of PSCs in the penile corpora and major pelvic ganglion at 1 and 3 days postoperatively. At 7 days, immunofluorescence of penile PSCs had disappeared and was diminished in the major pelvic ganglion. CLINICAL IMPLICATIONS: Placenta-derived stem cells may represent a future "off-the-shelf" treatment to mitigate against development of erectile dysfunction after radical prostatectomy or other forms of pelvic injury. STRENGTH & LIMITATIONS: Single dose injection of PSCs after injury resulted in maximal functional recovery and tissue regeneration at 6 weeks, and the results were maintained through 12 weeks. Strategies to optimize adult stem cell therapy might achieve more effective outcomes for human clinical trials. CONCLUSION: Human PSC therapy effectively restores the erectile tissue and function in this animal model. Thus, PSC therapy may provide an attractive modality to lessen the incidence of erectile dysfunction after pelvic neurovascular injury. Further improvement in tissue regeneration and functional recovery may be possible using multiple injections or systemic introduction of stem cells. Gu X, Thakker PU, Matz EL, et al. Dynamic Changes in Erectile Function and Histological Architecture After Intracorporal Injection of Human Placental Stem Cells in a Pelvic Neurovascular Injury Rat Model. J Sex Med 2020;17:400-411.