Precision-guidance vs Systematic Sampling: Optimizing Biopsy Assessment of Secondary Prostate Cancer Suspicious Multiparametric Magnetic Resonance Imaging Lesions.

PURPOSE: We assessed the diagnostic yield of consecutive transperineal targeted biopsy of multiparametric magnetic resonance imaging index lesion and secondary lesion and additive systematic biopsy in patients who received combined targeted biopsy+systematic biopsy of prostate. MATERIALS AND METHODS: Of 1,467 patients with targeted biopsy+systematic biopsy, analyses were restricted to 571 patients with index lesion+secondary lesion, Prostate Imaging-Reporting and Data System score ≥3. Index lesion was defined as having the greatest Prostate Imaging-Reporting and Data System score and/or lesion volume as opposed to secondary lesion. We retrospectively compared clinically significant prostate cancer rates (ie, Gleason Grade Group ≥2) between index lesion+secondary lesion and index lesion+secondary lesion+systematic biopsy. Subgroup analyses in men with ipsilateral index lesion+secondary lesion focused on contralateral systematic biopsy. Multivariable logistic regression analyses to predict any clinically significant prostate cancer included age, previous biopsies, prostate specific antigen density, respective index lesion/secondary lesion volumes, side relation, Prostate Imaging-Reporting and Data System strata, and number of targeted biopsy and systematic biopsy cores. RESULTS: Clinically significant prostate cancer rates for index lesion+secondary lesion vs index lesion+secondary lesion+systematic biopsy were 38% vs 42% (P = .2) at expense of significantly higher median number of biopsy cores (9 vs 25, P < .001). In the subgroup with ipsilateral index lesion+secondary lesion (n = 236), contralateral systematic biopsy detected clinically significant prostate cancer in 17%. In the narrower subgroup with ipsilateral index lesion+secondary lesion (n = 131) without any clinically significant prostate cancer, contralateral systematic biopsy detected clinically significant prostate cancer in 3.8%. Multivariable logistic regression analyses confirmed contralateral systematic biopsy as independent predictor, but performed similarly without systematic biopsy information (area under the curve 87.1% vs 86.6%). CONCLUSIONS: Targeted biopsy of secondary lesion should be included in targeted biopsy protocols due to added diagnostic information. However, for targeted biopsy of index lesion+secondary lesion additional systematic biopsy is of limited informative value in terms of overall clinically significant prostate cancer detection. However, when index lesion+secondary lesion are ipsilateral, contralateral systematic biopsy should be recommended for purpose of prostate lobe information. Our results indicate great potential to reduce systematic biopsy cores and associated potential morbidity, and warrant prospective evaluation.

Bilateral Peritoneal Flaps Reduce Incidence and Complications of Lymphoceles after Robotic Radical Prostatectomy with Pelvic Lymph Node Dissection-Results of the Prospective Randomized Multicenter Trial ProLy.

PURPOSE: The purpose of this study was to investigate the effect of a surgically constructed bilateral peritoneal flap (PIF) as an adjunct to robot-assisted radical prostatectomy (RARP) and pelvic lymph node dissection (PLND) on the incidence of lymphoceles. MATERIALS AND METHODS: A total of 530 men with localized prostate cancer underwent a RARP with bilateral extended standardized PLND in a prospective randomized controlled trial. In group A, a PIF was created by suturing the margins of the bladder peritoneum to the ipsilateral endopelvic fascia at 2 points on each side. In group B, no PIF was created. The patients were followed 30 and 90 days after the surgery to assess the incidence, extent and treatment of lymphoceles. RESULTS: Lymphoceles occurred in 22% of group A patients and 33% of group B patients (p=0.008). Symptomatic lymphoceles were observed in 3.3% of group A patients and 8.1% of group B patients (p=0.027). Lymphoceles requiring intervention occurred significantly less frequently in group A patients (1.3%) than in group B patients (6.8%, p=0.002). The median lymphocele size was 4.3 cm in group A and 5.0 cm in group B (p=0.055). No statistically significant differences were observed in minor or major complications unrelated to lymphocele, blood loss, or surgical time between groups A and B. CONCLUSIONS: Bilateral PIFs in conjunction with RARP and PLND significantly reduce the total incidence of lymphoceles, the frequency of symptomatic lymphoceles and the rate of associated secondary interventions.

Molecular margin status after radical prostatectomy using glutathione S-transferase P1 (GSTP1) promoter hypermethylation.

OBJECTIVE: To assess the potential for molecular staging in biopsies of the prostatic fossa after radical prostatectomy (RP) by searching for occult tumour cells through analysis of glutathione S-transferase P1 (GSTP1) methylation status. PATIENTS AND METHODS: We analysed 2446 biopsies: 2286 biopsies from a group of 254 patients with clinically organ-confined prostate cancer who underwent RP and 160 biopsies from a control group of 32 patients. After prostate gland excision, biopsies were obtained from defined areas of the prostatic fossa and bisected for histopathological and molecular genetics analyses. Results were related to clinicopathological data including tumour stage, lymph node status, resection status, tumour grading, initial PSA level, and biochemical recurrence. RESULTS: In total, 34 patients (13.4%) had at least one core positive for the GSTP1 promoter hypermethylation, six of whom (17.6%) were characterised as having a clinically localised tumour stage (pT2, pN0) and 28 (82.4%) as an advanced tumour stage (≥pT3 and/or pN1). GSTP1 promoter hypermethylation significantly correlated with tumour stage (P < 0.001), International Society of Urological Pathology grading (P = 0.001), lymph node status (P < 0.001), surgical margin status (P < 0.001), and biochemical recurrence (P = 0.001). Furthermore, in 46 patients (18.1%) further analysis led to a down- or upgrading of conventional surgical margin status. Classical R-status (margins of the specimen) is significantly superior to histological sampling from the fossa (P = 0.006) but not to GSTP1 analysis from the fossa (P = 0.227). CONCLUSION: For the detection of residual tumour in the fossa after RP in order to better predict recurrence, molecular GSTP1 promoter hypermethylation has some value; however, the classical R-status (margins of the specimen) is simpler and more widely applicable with similar results.

Reporting and grading of complications for intracorporeal robot-assisted radical cystectomy: an in-depth short-term morbidity assessment using the novel Comprehensive Complication Index®.

OBJECTIVE: To assess suitability of Comprehensive Complication Index (CCI®) vs. Clavien-Dindo classification (CDC) to capture 30-day morbidity after robot-assisted radical cystectomy (RARC). MATERIALS AND METHODS: A total of 128 patients with bladder cancer (BCa) undergoing intracorporeal RARC with pelvic lymph node dissection between 2015 and 2021 were included in a retrospective bi-institutional study, which adhered to standardized reporting criteria. Thirty-day complications were captured according to a procedure-specific catalog. Each complication was graded by the CDC and the CCI®. Multivariable linear regression (MVA) was used to identify predictors of higher morbidity. RESULTS: 381 complications were identified in 118 patients (92%). 55 (43%), 43 (34%), and 20 (16%) suffered from CDC grade I-II, IIIa, and ≥ IIIb complications, respectively. 16 (13%), 27 (21%), and 2 patients (1.6%) were reoperated, readmitted, and died within 30 days, respectively. 31 patients (24%) were upgraded to most severe complication (CCI® ≥ 33.7) when calculating morbidity burden compared to corresponding CDC grade accounting only for the highest complication. In MVA, only age was a positive estimate (0.44; 95% CI = 0.03-0.86; p = 0.04) for increased cumulative morbidity. CONCLUSION: The CCI® estimates of 30-day morbidity after RARC were substantially higher compared to CDC alone. These measurements are a prerequisite to tailor patient counseling regarding surgical approach, urinary diversion, and comparability of results between institutions.

Impact of obesity on perioperative, functional and oncological outcomes after robotic-assisted radical prostatectomy in a high-volume center.

OBJECTIVE: To compare surgical, oncological and functional outcomes between obese vs. normal-weight prostate cancer (PCa) patients treated with robotic-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: We assessed 4555 consecutive RARP patients from a high-volume center 2008-2018. Analyses were restricted to normal-weight vs. obese patients (≥ 30 kg/m2). Multivariable cox regression analyses (MVA) assessed the effect of obesity on biochemical recurrence (BCR), metastatic progression (MP), erectile function and urinary continence recovery. Analyses were repeated after propensity score matching. RESULTS: Before matching, higher rates of pathological Gleason Grade group ≥ 4 (14 vs. 18%; p = 0.004) and pT3 stage (33 vs. 35%; p = 0.016) were observed in obese patients, with similar observations for surgery time, blood loss and 30-day wound- and surgical complication rates. For normal-weight vs. obese patients, BCR- and MP-free rates were 86 vs. 85% (p = 0.97) and 97.5 vs.97.8% (p = 0.8) at 48 months. Similarly, rates of erectile function at 36 months and urinary continence at 12 months were 56 vs. 49% (p = 0.012) and 88 vs. 85% (p = 0.003), respectively. Before and after propensity score matching, obesity had no effect on BCR or MP, but a negative effect on erectile function (matched HR 0.87, 95%CI 0.76-0.99; p = 0.029) and urinary continence recovery (matched HR 0.91, 95%CI 0.84-0.98; p = 0.014). CONCLUSIONS: Obesity did not represent a risk factor of BCR or MP after RARP despite higher rates of adverse pathological features. However, obesity was associated with higher risk of perioperative morbidity and impaired functional outcomes. Such information is integral for patient counselling. Thus, weight loss before RARP should be encouraged.

Suitability of conventional systematic vs. MRI-guided targeted biopsy approaches to assess surgical treatment delay for radical prostatectomy.

OBJECTIVES: To assess if systematic (SBx) vs. transrectal or transperineal mpMRI-ultrasound targeted combined with systematic (TBx + SBx) biopsy confer different effects on treatment delay to radical prostatectomy measured as Gleason grade group (GGG) upgrade of prostate cancer (PCa). MATERIALS AND METHODS: We relied on a multi-institutional cohort of localized PCa patients who underwent RP in Martini-Klinik, Hamburg, or Prostate Center Northwest, Gronau, between 2014 and 2022. Analyses were restricted to PCa GGG 1-3 diagnosed at SBx (n = 4475) or TBx + SBx (n = 1282). Multivariable logistic regression modeling (MVA) predicting RP GGG upgrade of ≥ 1 was performed separately for SBx and TBx + SBx. RESULTS: Treatment delay to RP of < 90, 90-180 and 180-365 days was reported in 59%, 35% and 6.2% of SBx and in 60%, 34% and 5.9% of the TBx + SBx patients, respectively. Upgrade to GGG ≥ 4 at RP was detected in 15% of SBx patients and 0.86% of TBx patients. In MVA performed for SBx, treatment delay yielded independent predictor status (OR 1.17 95% CI 1.02-1.39, p = 0.028), whereas for TBx + SBx MVA, statistical significance was not achieved. CONCLUSION: Treatment delay remained independently associated with radical prostatectomy GGG upgrade after adjustment for clinical variables in the patients diagnosed with SBx alone, but not in those who received combined TBx + SBx. These findings can be explained through inherent misclassification rates of SBx, potentially obfuscating historical observations of natural PCa progression and potential dangers of treatment delay. Thus, mpMRI-guided combined TBx + SBx appears mandatory for prospective delay-based examinations of PCa.

Feasibility of robot-assisted radical prostatectomy in men at senior age ≥75 years: perioperative, functional, and oncological outcomes of a high-volume center.

OBJECTIVES: The aim of this study was to assess whether age ≥75 years impairs surgical, functional, and oncological outcomes after robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: Patients with prostate cancer (PCa) were stratified in ≥75(n = 669) vs. <70 years(n = 8,268). Multivariable cox regression analyses (MVA) tested for effect of senior age on erectile function-, urinary continence-recovery, biochemical recurrence (BCR), and metastatic progression (MP). RESULTS: RARP duration, blood loss, and 30d complication rates were similar between groups. For patients ≥75 vs. <70 years, rates of erectile function after 36 and urinary continence after 12 months were 27 vs. 56% (p < 0.001) and 85 vs. 86% (p = 0.99), respectively. Mean quality of life (QoL) score after 12 months improved in both groups (p = 0.9). At 48 months, BCR- and MP-free rates were 77 vs. 85% (p < 0.001) and 97 vs. 98% (p = 0.3), respectively. MVA confirmed the negative effect of senior age on erectile function but no significant effect on urinary continence, BCR or MP, before and after propensity score matching. CONCLUSION: Apart from erectile function, senior age has no significant effect on urinary continence recovery, BCR- or MP-free rates after RARP. Post-RARP QoL improved even in senior patients. Modern therapy of senior PCa patients should be based on individual counseling than just age.

Oncologic impact of concomitant prostate cancer characteristics at the time of radical cystoprostatectomy for bladder cancer: a population-based analysis.

OBJECTIVE: The aim of this study was to evaluate the prognostic impact of concomitant prostate cancer (PCa) of the cancer-specific mortality (CSM) in the aging patient's papulation with bladder cancer (BCa) treated with radical cystoprostatectomy (RCP). MATERIALS AND METHODS: Within the SEER database (2004-2015), 1468 patients were treated with RCP for BCa harboring histopathological PCa findings. To account for other cause mortality (OCM), multivariable competing risk regression (CRR) tested for potential BCa-CSM differences according to PCa characteristics risk factors predicting CSM. RESULTS: CRR analysis revealed that only following BCa characteristics, as high pathological tumor stages(Ta/Tis/T1 [REF.] vs. T2; HR 2.03, 95% CI: 1.16-3.57, p = 0.014 vs. T3; HR 4.32, 95% CI: 2.45-7.61, p < 0.001 vs. T4; HR 5.06, 95% CI: 2.77-9.22, p < 0.001), as well unfavorable BCa grade IV (Grade I-II [REF.] vs. Grade IV; HR 0.58, 95% CI: 0.35-0.98, p < 0.041) achieved independent predictor status of CSM. With regard to PCa characteristics, none of the covariates yielded independent predictor status of CSM. CONCLUSIONS: Our study, based on the largest population cohort, demonstrates that even in organ-confined BCa patients, concomitant PCa as second malignancy does not represent a risk factor for survival.

Perioperative and Postoperative Outcomes of Robot-Assisted Radical Prostatectomy in Prostate Cancer Patients with Prior Transurethral Subvesical Deobstruction: Results of a High-Volume Center.

PURPOSE: Prostate cancer patients who are scheduled for robot-assisted radical prostatectomy often have a history of transurethral resection or laser enucleation of the prostate as treatment of benign prostatic hyperplasia. We examined if these patients have impaired surgical, functional and oncologic outcomes compared to those who have no symptom burden of moderate to severe benign prostatic hyperplasia and no previous transurethral resection or laser enucleation of the prostate. MATERIALS AND METHODS: We compared 368 robot-assisted radical prostatectomy patients with previous transurethral resection or laser enucleation of the prostate (group A) to 4,945 robot-assisted radical prostatectomy patients without transurethral resection or laser enucleation of the prostate and without moderate or severe benign prostatic hyperplasia symptoms (group B) at a high-volume robot-assisted radical prostatectomy center. Multivariable Cox regression analyses assessed impact of transurethral resection or laser enucleation of the prostate on erectile function and urinary continence recovery, biochemical recurrence or metastatic progression. Analyses were repeated after propensity score matching. RESULTS: No relevant differences in surgical outcomes, such as surgical margin and 30-day complications rates, were observed. Urinary continence recovery rates at 12 months were 67% vs 74% (group A vs B; p <0.001). Erectile function recovery rates at 24 months were 52% vs 62% (p <0.001). Biochemical recurrence-free rates at 36 months were identical, at 87.3% vs 87.8%. Before and after propensity score matching, transurethral resection or laser enucleation of the prostate negatively affected erectile function recovery (matched HR 0.68, 95% CI 0.53-0.88; p=0.003) in multivariable Cox regression analyses. Similarly, transurethral resection or laser enucleation of the prostate had negative effect on urinary continence recovery (HR 0.84, 95% CI 0.73-0.97; p=0.015) but no effect on biochemical recurrence or metastatic progression. CONCLUSIONS: Previous transurethral resection or laser enucleation of the prostate does not negatively impact surgical, complication-related, and oncologic outcomes if the robot-assisted radical prostatectomy is performed by highly experienced surgeons. However, transurethral resection or laser enucleation of the prostate negatively affects erectile function and urinary continence recovery.

Superior early and long-term continence following early micturition on day 2 after robot-assisted radical prostatectomy: a randomized prospective trial.

PURPOSE: To elucidate early and long-term continence and patient comfort depending on type and duration of catheterization after robot-assisted radical prostatectomy. METHODS: 198 patients were randomized prospectively into three groups (May 2016-July 2017): A transurethral catheter with micturition on postoperative day (POD) 5 was placed in the control group (TD5); a suprapubic tube (SPT) with micturition on POD 5 was placed in the group SD5 or with micturition on POD 2 in group SD2, respectively. Questionnaires were used for catheter-related satisfaction. Functional outcome analysis included residual volume analysis, uroflowmetry, IPSS, 12-h pad test, and daily pad use. Follow-up was conducted up to 12 months. RESULTS: Postoperative comfort and catheter-related complications were similar in the three groups. However, on the day of catheter removal, continence was significantly better in the 12-h pad test for the SD2 group with 14 ml vs. 30 ml (TD5) and 24 ml (SD5), p = 0.007. Median residual urine volume between the groups was comparable with 17 ml in TD5, 7 ml in SD5, and 11 ml in SD2, (p = 0.07). Postoperative IPSS did not differ significantly in the follow-up period. After 4 weeks, 63% of the patients in SD2 were continent (no pad/day) compared to 33% in TD5 and 41% in SD5, p = 0.004. After 12 months, 76% were continent in TD5, 87% in SD5, and 94% in SD2, p = 0.023. CONCLUSIONS: Early micturition after SPT placement in robotic radical prostatectomy seems to be beneficial without an increased risk of complications.

Tumor complexity and the impact on MIC and trifecta in robot-assisted partial nephrectomy: a multi-center study of over 500 cases.

PURPOSE: To demonstrate the surgical feasibility of robot-assisted partial nephrectomy for complex renal masses with comparison of low/intermediate risk versus high-risk tumors according to the PADUA score. METHODS: Since 2008, 538 robot-assisted partial nephrectomies were performed at three German robotic centers. Both the MIC (margin, ischemia, complications) criteria and trifecta were applied. RESULTS: 60.1% of the tumors were of low and intermediate complexity (PADUA score 6-9, n = 326, group A), while 39.9% were highly complex (n = 212, score ≥ 10, B). Median clinical tumor size was 28 in A versus 37 mm in B (p < 0.001). There was no significant difference in terms of operative time (160 vs. 163 min, p = 0.20); ischemia time was slightly longer for B (11 vs. 12 min, p < 0.001). There were no significant differences for intra- (3.4%, A, vs. 6.6%, B, p = 0.10) or postoperative (21.5%, A, vs. 25.5%, B, p = 0.30) complication rates. There was a median eGFR decrease of - 9.4 (A) versus - 15.1 (B) ml/min (p < 0.001) on discharge. Histopathology revealed an R1 margin rate of 3.4% for the low/intermediate versus 6.1% for the high complexity group (p = 0.14). MIC criteria were fulfilled in 81.9% (A) versus 75.5% (B, p = 0.11) and trifecta criteria in 74.2% (A) versus 68.93% (B, p = 0.26). CONCLUSIONS: Complication rates, histopathology results as well as quality criteria as indicated by MIC and trifecta were similar for high and low complexity groups. Therefore, robot-assisted partial nephrectomy is a safe and feasible option also in highly complex tumors.

Fluorescence-supported lymphography and extended pelvic lymph node dissection in robot-assisted radical prostatectomy: a prospective, randomized trial.

PURPOSE: To demonstrate the benefits of fluorescence-supported extended pelvic lymph node dissection (ePLND) compared to regular ePLND in robot-assisted radical prostatectomy. METHODS: 120 patients with intermediate- or high-risk prostate cancer were prospectively randomized (1:1): in the intervention group, indocyanine green (ICG) was injected transrectally into the prostate before docking of the robot. In both groups, ePLND was performed including additional dissection of fluorescent lymph nodes (LN) in the ICG group. RESULTS: After drop-out of two patients, 59 patients were allocated to the control (A) and intervention group (B) with a median PSA of 8,6 ng/ml. Median console time was 159 (A) vs. 168 (B) min (p = 0.20) with a longer time for ICG-ePLND: 43 (A) vs. 55 min (B) (p = 0.001). 2609 LN were found with significantly more LN after ICG-supported ePLND with a median of 25 vs. 17 LN in A (p < 0.001). Nodal metastases were detected in 6 patients in A (25 cancerous LN) vs. 9 patients in B (62 positive LN) (p = 0.40). In seven of nine patients, ICG-ePLND identified at least one cancer-positive LN (sensitivity 78%), 27 of 62 cancerous LN were fluorescent. Symptomatic lymphocele occurred in one patient in a and in three patients in b (p = 0.62). After a median follow-up of 22.9 months, PSA levels were similar. CONCLUSIONS: While ICG-ePLND seems to be beneficial for a better understanding of the lymphatic drainage and a more meticulous diagnostic approach, the sensitivity is not sufficient to recommend stand-alone ICG lymph node dissection.

Are there limits of robotic partial nephrectomy? TRIFECTA outcomes of open and robotic partial nephrectomy for completely endophytic renal tumors.

BACKGROUND: To compare the outcomes of robot-assisted (RAPN) and open partial nephrectomy (OPN) for completely endophytic renal tumors. METHODS: Consecutive patients undergoing OPN or RAPN for entirely endophytic tumors in four high-volume centers between 2008 and 2016 were identified. Endophytic masses were identified based on sectional imaging. Patient characteristics and surgical outcome were compared using Mann-Whitney-U-test and chi-squared-tests. Uni- and multivariate analyses were performed to identify predictors of TRIFECTA achievement and excisional volume loss. RESULTS: Out of 1128 patients, 10.9% (64) of RAPN and 13.9% (76) of OPN underwent surgery for entirely endophytic tumors. Operative time was longer for RAPN (169 vs 140 min, P = 0.03) while ischemia time was shorter (13 vs 18 min, P = 0.001). Complication rates were comparable (21% OPN vs 22% RAPN, P = 0.91) and TRIFECTA achievement was not different between the groups (68% OPN vs 75% RAPN, P = 0.39). In multivariate analyses type of surgery was not associated with TRIFECTA achievement or excisional volume loss. Here, only tumor complexity (OR 0.48, P = 0.001) and size (OR 1.01, P = 0.002) were independent predictors. CONCLUSION: For entirely endophytic tumors, both RAPN and OPN offer good TRIFECTA achievement. This encourages the use of NSS even for these highly complex tumors using the surgeon's preferred approach.

Postoperative patient comfort in suprapubic drainage versus transurethral catheterization following robot-assisted radical prostatectomy: a prospective randomized clinical trial.

PURPOSE: To evaluate the impact of the type of urinary diversion (suprapubic vs. transurethral catheterization) on patients' postoperative pain after radical prostatectomy, development of bacteriuria and long-term functional results. METHODS: A randomized, prospective clinical trial was performed including 160 patients who underwent robot-assisted radical prostatectomy after randomization into two groups: intraoperatively, a transurethral catheter (control group) or an additional suprapubic tube (with removal of the transurethral catheter in the morning of postoperative day 1; intervention group) was placed. Primary study endpoint was postoperative pain objectified by the numeric rating scale questionnaire. Secondary endpoints were bacteriuria after catheter removal and functional outcomes after up to 2 years of follow-up. RESULTS: There were no significant differences in demographic and perioperative data. Starting on postoperative day 2, patients in the suprapubic diversion group had significantly less pain on every time point preceding the removal of the catheter compared to the control cohort with a median overall numeric rating score on postoperative day 1-4 of 2.4 points in the transurethral versus 1.3 in the intervention group (p = 0.012). No statistical difference was found in postoperative bacteriuria and complications as well as in functional results, quality of life and incontinence rates after a median follow-up of 22 months. CONCLUSIONS: Suprapubic drainage in robot-assisted radical prostatectomy shows significantly decreased pain levels during the catheterization period compared to the transurethral diversion without compromising long-term functional results. Intraoperative placement of a suprapubic tube should be discussed as a standard procedure for further improvement of patients' postoperative comfort.

Development of a standardised training curriculum for robotic surgery: a consensus statement from an international multidisciplinary group of experts.

OBJECTIVES: To explore the views of experts about the development and validation of a robotic surgery training curriculum, and how this should be implemented. MATERIALS AND METHODS: An international expert panel was invited to a structured session for discussion. The study was of a mixed design, including qualitative and quantitative components based on focus group interviews during the European Association of Urology (EAU) Robotic Urology Section (ERUS) (2012), EAU (2013) and ERUS (2013) meetings. After introduction to the aims, principles and current status of the curriculum development, group responses were elicited. After content analysis of recorded interviews generated themes were discussed at the second meeting, where consensus was achieved on each theme. This discussion also underwent content analysis, and was used to draft a curriculum proposal. At the third meeting, a quantitative questionnaire about this curriculum was disseminated to attendees to assess the level of agreement with the key points. RESULTS: In all, 150 min (19 pages) of the focus group discussion was transcribed (21 316 words). Themes were agreed by two raters (median agreement κ 0.89) and they included: need for a training curriculum (inter-rater agreement κ 0.85); identification of learning needs (κ 0.83); development of the curriculum contents (κ 0.81); an overview of available curricula (κ 0.79); settings for robotic surgery training ((κ 0.89); assessment and training of trainers (κ 0.92); requirements for certification and patient safety (κ 0.83); and need for a universally standardised curriculum (κ 0.78). A training curriculum was proposed based on the above discussions. CONCLUSION: This group proposes a multi-step curriculum for robotic training. Studies are in process to validate the effectiveness of the curriculum and to assess transfer of skills to the operating room.

Robot-assisted radical prostatectomy for the treatment of radiation-resistant prostate cancer: surgical, oncological and short-term functional outcomes.

OBJECTIVE: The objective of this study was to assess the surgical, oncological and short-term functional outcomes in patients undergoing salvage robot-assisted radical prostatectomy (SRARP) for the treatment of radiation-resistant prostate cancer. PATIENTS AND METHODS: The records of 3,500 men who underwent RARP from February 2006 to July 2011 were retrospectively reviewed. All peri- and postoperative data were recorded prospectively in our database. A total of 13 patients (0.37%) who had undergone SRARP for the treatment of radiation-resistant prostate cancer were identified. RESULTS: The primary treatment was external beam radiotherapy in 7 patients (53.8%) and brachytherapy in 6 patients (46.2%). The interval from radiotherapy to biochemical recurrence (BCR) varied from 12 to 108 months (median 48.9). Neurovascular bundle preservation was performed in 3 patients (23.1%). No intraoperative or major complications were encountered. Minor complications were encountered in 4 patients (30.7%). At 12 months, 7 patients were continent (53.8%), 3 exhibited mild incontinence (23.1%) and 3 (23.1%) were incontinent. Regarding potency, none of the patients were potent at 6 months, but 3 patients (23.1%) were potent at 1 year. Regarding BCR, 3 of the patients (23.1%) never reached a prostate-specific antigen nadir of zero, and during the follow-up period only 3 patients (23.1%) exhibited BCR. No disease-specific mortality was evident during follow-up. CONCLUSIONS: Although early in its development, it appears that SRARP is technically feasible and offers satisfactory surgical, oncological and short-term functional outcomes.

Robot-assisted radical prostatectomy in patients with a pathologic prostate specimen weight ≥100 grams versus ≤50 grams: surgical, oncologic and short-term functional outcomes.

INTRODUCTION: The objective of this study is to evaluate the surgical, oncological and short-term functional outcomes in patients with a pathologic prostate specimen weight ≥100 g versus patients with a pathologic prostate specimen weight ≤50 g undergoing robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: The records of 4,000 men who underwent RARP from February 2006 to April 2012 were reviewed retrospectively. A total of 185 men had a pathologic prostate specimen weight ≥100 g (group A). A matched pairs analysis was performed using our database to identify men with a pathologic prostate specimen weight ≤50 g but with equivalent clinicopathologic characteristics to serve as the control group (group B). RESULTS: Our results indicated that although the intraoperative results were more than satisfying in patients with large glands, there is a significant increase in blood loss, operative time needed, increased need for bladder neck reconstruction as well as an increase in intraoperative complications. Nevertheless, patients with large glands exhibit less aggressive tumors, less positive surgical margins and a lower incidence of biochemical recurrence. Regarding functional outcomes, patients with larger glands had no difference regarding continence rates when compared to patients with smaller glands but exhibited significantly lower potency rates. CONCLUSIONS: Although RARP in patients with a pathologic prostate specimen weight ≥100 g is technically challenging, in experienced hands it can be considered a safe procedure with excellent surgical, oncological and functional outcomes. Nevertheless, this conclusion is limited, in that it is from a single institution with a large case volume and may not be reflective of outcomes at centers with smaller volumes and less experience.