Robotic versus laparoscopic radical nephrectomy: a large multi-institutional analysis (ROSULA Collaborative Group).

OBJECTIVE: To compare the outcomes of robotic radical nephrectomy (RRN) to those of laparoscopic radical nephrectomy (LRN) for large renal masses. METHODS: This was a retrospective analysis of RRN and LRN cases performed for large (≥ cT2) renal masses from 2004 to 2017 and collected in the multi-institutional international database (ROSULA: RObotic SUrgery for LArge renal masses). Peri-operative, functional, and oncologic outcomes were compared between each approach. Descriptive analyses were performed and presented as medians with interquartile ranges. Inverse probability of treatment weighting-adjusted multivariable analyses were used to identify predictors of peri-operative complications. Kaplan-Meier analysis and Cox regression models were used to assess survival outcomes. RESULTS: A total of 941 patients (RRN = 404, LRN = 537) were identified. There was no difference in terms of gender, age, and clinical tumor size. Over the study period, RRN had an annual increase of 11.75% (95% CI [7.34, 17.01] p < 0.001) and LRN had an annual decline of 5.39% (95% CI [-6.94, -3.86] p < 0.001). Patients undergoing RRN had higher BMI (27.6 [IQR 24.8-31.1] vs. 26.5 [24.1-30.0] kg/m2, p < 0.01). Operative duration was longer for RRN (185.0 [150.0-237.2] vs. 126 [90.8-180.0] min, p < 0.001). Length of stay was shorter for RRN (3.0 [2.0-4.0] vs. 5.0 [4.0-7.0] days, p < 0.001). RRN cases presented more advanced disease (higher pathologic staging [pT3-4 52.5 vs. 24.2%, p < 0.001], histologic grade [high grade 49.3 vs. 30.4%, p < 0.001], and rate of nodal disease [pN1 5.4 vs. 1.9%, p < 0.01]). Surgical approach did not represent an independent risk factor for peri-operative complications (OR 1.81 95% CI [0.97-3.39], adjusted p = 0.2). The main study limitation is the retrospective design. CONCLUSIONS: This study represents the largest known multi-center comparison between RRN and LRN. The two procedures seem to offer similar peri-operative outcomes. Notably, RRN has been increasingly utilized, especially in the setting of more advanced and surgically challenging disease without increasing the risk of peri-operative complications.

Healthcare utilization in men with poorer sexual and urinary function recovery following robot-assisted radical prostatectomy.

PURPOSE: Robotic radical prostatectomy focuses on oncologic cure, urinary continence and sexual function recovery. However, little is known about the effect of declines in urinary continence and sexual function on healthcare utilization. We aim to identify these factors. MATERIALS AND METHODS: From March 2011 to September 2013, all men undergoing robotic prostatectomy within our healthcare system were enrolled. Men completed the expanded prostate cancer index composite-26 survey at the time of diagnosis and 90 days post-operatively. Patients were stratified according to change in scores in the sexual function and urinary incontinence domains. Patient, treatment and post-op utilization patterns were examined for association with the extent of decline in sexual function and urinary continence. Multivariate linear regression was used to identify factors independently associated with decline in continence and sexual function. RESULTS: A total of 411 men who completed the baseline survey and at 90 days postoperatively were included. On multivariate linear regression, younger age (p < 0.01), higher preoperative sexual function (< 0.01), single marital status (p = 0.04) and more post-surgery email contacts (p = 0.04) were associated with higher declines in sexual function. For continence, no family history of prostate cancer (p = 0.01), higher baseline continence (p < 0.01) and more post-surgery physical therapy visits (p < 0.01) were associated with higher declines. CONCLUSIONS: Patients with the poorest quality of life outcomes at 90 days post-operatively were more likely to seek care via email and physical therapy encounters related to sexual function and urinary incontinence, respectively. This suggests that maximizing post-treatment quality of life can potentially reduce healthcare utilization.

Laparoscopic wedge fundectomy for collis gastroplasty creation in patients with a foreshortened esophagus.

OBJECTIVE: To assess the outcome of a laparoscopic wedge-fundectomy Collis gastroplasty for a short esophagus during fundoplication and hiatal hernia repair. BACKGROUND: The Collis gastroplasty provides a surgical solution for a foreshortened esophagus but has been associated with postoperative dysphagia and esophagitis. METHODS: We identified 150 patients who underwent a Collis gastroplasty from 1998 to 2012, and of these, 85 patients underwent laparoscopic procedures using the wedge-fundectomy technique. RESULTS: The median age of the 85 patients (42 men/43 women) was 66 years (range, 37-84 years). A Nissen fundoplication was added to the Collis gastroplasty in 56 patients (66%) and a Toupet fundoplication in 29 patients. No patient had a staple line leak or abscess, and the median hospital stay was 3.5 days (interquartile range, 3-4.5 days). At a median follow-up of 12 months, 93% of patients were free of heartburn. Dysphagia was significantly less common after surgery (preoperative: 58% vs postoperative: 16%; P < 0.0001). New-onset dysphagia developed in only 2 patients. An upper endoscopy was performed in 54 patients at a median of 6 months after surgery, and erosions above the fundoplication were seen in 6 patients (11%). A small (1-2 cm) recurrent hernia was seen in 2 patients (2.4%). CONCLUSIONS: The laparoscopic wedge-fundectomy Collis gastroplasty can be performed safely and is associated with a low prevalence of new-onset dysphagia and esophagitis. The addition of a Collis gastroplasty to an antireflux operation is an effective strategy in patients with short esophagus, and its more liberal use is encouraged.

Neoadjuvant Leuprolide Therapy with Radical Prostatectomy: Long-term Effects on Health-related Quality of Life.

BACKGROUND: Neoadjuvant androgen ablation (neoadjuvant androgen deprivation therapy [NADT]) is used prior to radical prostatectomy, contrary to guidelines, but its long-term effects on quality of life is unknown. OBJECTIVE: To determine the effect of NADT on patient's long-term recovery following surgery. DESIGN, SETTING, AND PARTICIPANTS: From March 2011 to August 2013, 5808 men with newly diagnosed prostate were followed up to 24 mo. A cohort of men who received NADT prior to robotic-assisted laparoscopic prostatectomy (RALP; n=51) was compared 1:3 with a matched group that underwent RALP only (n=153). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patients were matched on Charlson comorbidities, biopsy Gleason score, and node status on final pathology. The Kruskall-Wallis test was used to compare the groups on their bowel, urinary, sexual, and hormonal domains of the 26-item Expanded Prostate Cancer Index Composite at baseline and at 1, 3, 6, 12, 18, and 24 mo postoperatively. RESULTS AND LIMITATIONS: The urinary irritative, urinary incontinence, and bowel domains were similar in the two groups during the 24 mo (p=0.832, 0.901, and 0.732, respectively). In the hormonal domain, the NADT group did worse (p<0.001). The sexual domain was also worse for the NADT group. However, when accounting for nerve sparing, there was no significant difference in sexual outcomes between the two groups (p=0.069). CONCLUSIONS: Patients who received NADT prior to RALP do not have worse sexual function, but have worse hormonal scores for up to 2yr after surgery. PATIENT SUMMARY: Neoadjuvant androgen deprivation therapy (NADT) is administered prior to robotic-assisted laparoscopic prostatectomy (RALP), contrary to clinical guidelines. NADT may not have worse sexual function outcomes up to 2yr after RALP.

The association of race and survival from sepsis after injury.

Genetic variation is associated with outcome disparity in critical illness. We sought to determine if race is independently associated with the development of posttraumatic sepsis and subsequent related mortality. Our Intensive Care Unit database was queried for admissions from January 1, 2000 to June 30, 2007. Patients were prospectively followed for sepsis (Any four of the following symptoms: temperature > or =38 degrees C, heart rate (HR) > or =90 b/m, RR > or =20 b/m (or PaCO2 < or =32 mm Hg), white blood cell count (WBC) > or =12, or vasopressor requirement all with an infectious source). White, Black, Hispanic, and Asian groups were defined. "Other" race was excluded. Most of the 3998 study patients were male (3157, 79.0%). Blunt trauma (2661, 66.6%) predominated. Six-hundred-seventy-seven (16.9%) met sepsis criteria. Mortality was 14.0 per cent (560). Sepsis was increased in Asians versus all others combined (23.7% vs. 16.1%). Race was independently associated with sepsis (adjusted odds ratio (OR) 1.12 (1.01-1.24), P value = 0.03). Sepsis associated mortality was 36.9 per cent (250/677). Black race demonstrated an increased survival versus all others after sepsis (25.4% vs. 37.7%) but this was not statistically significant (adjusted OR 0.96 (0.73-1.18), P value = 0.71). Race is independently associated with posttraumatic sepsis and possibly subsequent sepsis associated mortality. Further related study is needed with the ultimate goal of genetically based treatments for the prevention and treatment of sepsis after injury.

Effect of Obesity and Overweight Status on Complications and Survival After Minimally Invasive Kidney Surgery in Patients with Clinical T2-4 Renal Masses.

Objective: To evaluate the effect of obesity and overweight on surgical, functional, and survival outcomes in patients with large kidney masses after minimally invasive surgery. Materials and Methods: Within a multicenter multinational dataset, patients found to have ≥cT2 renal mass and treated with minimally invasive (laparoscopic or robotic) kidney surgery (radical or partial nephrectomy) during the period 2003 to 2017 were abstracted. They were stratified according to the body mass index classes as normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2). Mixed models and Cox proportional hazard regression tested differences in complication rates, estimated glomerular filtration rate (eGFR) change over time, overall mortality (OM), and disease recurrence (DR) rates. Results: Of 812 patients, 30.6% were normal weight, 42.7% were overweight, and 26.7% obese. Overweight (odds ratio 0.82, 95% confidence interval [CI]: 0.51-1.31, p = 0.406) and obese patients (OR: 0.81, 95% CI: 0.44-1.47, p = 0.490) experienced similar complication rates than normal weight. Moreover, no statistically significant differences in eGFR were found for overweight (p = 0.129) or obese (p = 0.166) patients compared to normal weight. However, higher OM rates were recorded in overweight (hazard ratio [HR] 3.59, 95% CI: 1.03-12.51, p = 0.044), as well as in obese, patients (HR 7.83, 95% CI: 2.20-27.83, p = 0.002). Similarly, higher DR rates were recorded in obese (HR 2.76, 95% CI: 1.40-5.44, p = 0.003) patients. Conclusions: Obese and overweight patients do not experience higher complication rates or worse eGFR after minimally invasive kidney surgery, which therefore can be deemed feasible and safe also in this subset of patients. Nevertheless, obese and overweight patients seem to carry a higher risk of OM, and therefore, they should undergo a strict follow-up after surgery.

Nephrometry score matched robotic vs. laparoscopic vs. open partial nephrectomy.

To compare perioperative outcomes in the three most common partial nephrectomy modalities: robotic (RPN), laparoscopic (LPN), and open (OPN), matched for nephrometry scores. Patients aged 16-85 who underwent RPN, LPN, or OPN from 2007 to 2014 for localized renal carcinoma within our healthcare system were enrolled. Age, sex, body mass index, and Charlson Comorbidity Index (CCI) as well as perioperative outcomes of estimated blood loss (EBL), length of hospital stay (LOS), ischemia time (IT), change in eGFR, positive margin rate, operative time (OT), and emergency room visit rates were compared between RPN, LPN, and OPN using the R.E.N.A.L nephrometry score. A total of 862 patients underwent partial nephrectomy (523 LPN, 176 OPN, and 163 RPN). Patients who underwent OPN were significantly older, and had higher nephrometry scores and CCI. When matched for nephrometry scores, minimally invasive (LPN and RPN) compared to OPN had lower EBL (< 0.0001), shorter LOS (< 0.0001), shorter IT (< 0.001), and less change in eGFR (< 0.001), particularly in nephrometry scores higher than 8 (0.0099). Comparing RPN with LPN, RPN had significantly shorter OT in all nephrometry scores (< 0.001); shorter IT and LOS in nephrometry scores higher than 7. Our study suggests that minimally invasive partial nephrectomy may have superior outcomes to OPN when matched by nephrometry scores, particularly at higher scores and for RPN. This finding may contribute to a surgeon's decision in the approach to partial nephrectomy.

Does the Level of Assistant Experience Impact Operative Outcomes for Robot-Assisted Partial Nephrectomy?

PURPOSE: A skilled assistant surgeon is presumed necessary during robot-assisted partial nephrectomy (RAPN) to minimize warm ischemia time (WIT) and to facilitate complex renorrhaphy. Studies observing impact of resident participation have focused on robotic prostatectomies, showing no impact on core surgical outcomes. Herein, we evaluated the level of experience of the bedside assistant and its impact on perioperative outcomes in RAPN. MATERIALS AND METHODS: All RAPN cases in our healthcare system from January 2011 to December 2013 were retrospectively reviewed. The cases were divided into teaching and nonteaching hospitals. There were 18 fellowship-trained attending surgeons. At teaching hospitals, surgeries were performed by an attending physician and postgraduate year (PGY)-2 or PGY-3 resident at bedside; at nonteaching hospitals, surgeries were performed by two attending surgeons. We compared age, gender, body mass index, Charlson comorbidity index, operative difficulty by R.E.N.A.L. nephrometry score, and operative outcomes (WIT, estimated blood loss, operative time (OT), positive margin rate, length of stay (LOS), postoperative glomerular filtration rate, and readmission rate). RESULTS: Of the 170 patients captured, 162 had R.E.N.A.L. nephrometry score and WIT: 112 from teaching hospitals and 50 from nonteaching hospitals. Patient characteristics were equivalent between both cohorts with the exception of the R.E.N.A.L. score, which was higher (6.3 vs 5.7, p = 0.046) in the teaching hospitals cohort. Regarding operative outcomes, we noted an overall increase in LOS by 1 day (p = 0.001) and OT by 16 minutes (p = 0.011) in the teaching hospitals. CONCLUSION: We observed that increased LOS was the only clinically relevant measure negatively impacted by resident physician involvement during RAPN.

Effect of a Smoking Cessation Program on Sexual Function Recovery Following Robotic Prostatectomy at Kaiser Permanente Southern California.

INTRODUCTION: The association between cigarette smoking and erectile dysfunction has been well established. Studies demonstrate improvements in erectile rigidity and tumescence as a result of smoking cessation. Radical prostatectomy is also associated with worsening of erectile function secondary to damage to the neurovascular bundles. To our knowledge, no previous studies have examined the relationship between smoking cessation after prostate cancer diagnosis and its effect on sexual function following robotic prostatectomy. We sought to demonstrate the utility of a smoking cessation program among patients with prostate cancer who planned to undergo robotic prostatectomy at Kaiser Permanente Southern California. METHODS: All patients who underwent robotic prostatectomy between March 2011 and April 2013 with known smoking status were included, and were followed-up through November 2014. All smokers were offered the smoking cessation program, which included wellness coaching, tobacco cessation classes, and pharmacotherapy. Patients completed the Expanded Prostate Cancer Index Composite-26 (EPIC-26) health-related quality-of-life (HR-QOL) survey at baseline and postoperatively at 1, 3, 6, 12, 18, and 24 months. There were 2 groups based on smoking status: Continued smoking vs quitting group. Patient's age, Charlson Comorbidity Score, body mass index, educational level, median household income, family history of prostate cancer, race/ethnicity, language, nerve-sparing status, and preoperative/postoperative clinicopathology and EPIC-26 HR-QOL scores were examined. A linear regression model was used to predict sexual function recovery. RESULTS: A total of 139 patients identified as smokers underwent the smoking cessation program and completed the EPIC-26 surveys. Fifty-six patients quit smoking, whereas 83 remained smokers at last follow-up. All demographics and clinicopathology were matched between the 2 cohorts. Smoking cessation, along with bilateral nerve-sparing status, were the only 2 modifiable factors associated with improved sexual function after prostatectomy (6.57 points, p = 0.0226 and 8.97 points, p = 0.0485, respectively). CONCLUSION: In the setting of robotic prostatectomy, perioperative smoking cessation is associated with a significant improvement in long-term sexual functional outcome when other factors are adjusted.

Robot-Assisted Excision of a Urachal Cyst Causing Dyspareunia and Dysorgasmia: Report of a Case.

BACKGROUND: Urachal remnants are a group of rare anatomical anomalies that include cysts, diverticula, and tumors. We present a case of a young female patient with dyspareunia and dysorgasmia related to a urachal cyst. CASE: A patient with unique presentation of urachal cyst treated robotically. Patient had complete resolution of symptoms postoperatively. CONCLUSION: Robot-assisted excision of the urachal remnant provided durable symptom relief.

Laparoscopic versus open repair of paraesophageal hernia: the second decade.

BACKGROUND: A decade ago we reported that laparoscopic repair of paraesophageal hernia (PEH) had an objective recurrence rate of 42% compared with 15% after open repair. Since that report we have modified our laparoscopic technique. The aim of this study was to determine if these modifications have reduced the rate of objective hernia recurrence. STUDY DESIGN: We retrospectively identified all patients that had primary repair of a PEH with ≥ 50% of the stomach in the chest from May 1998 to January 2010 with objective follow-up by videoesophagram. The finding of any size of hernia was considered to be recurrence. RESULTS: There were 73 laparoscopic and 73 open PEH repairs that met the study criteria. There were no significant differences in gender, body mass index, or prevalence of a comorbid condition between groups. The median follow-up was similar (12 months laparoscopic versus 16 months open; p = 0.11). In the laparoscopic group, 84% of patients had absorbable mesh reinforcement of the crural closure and 40% had a Collis gastroplasty, compared with 32% and 26%, respectively, in the open group. A recurrent hernia was identified in 27 patients (18%), 9 after laparoscopic repair and 18 after open repair (p = 0.09). The median size of a recurrent hernia was 3 cm, and the incidence of recurrence increased yearly in those with serial follow-up with no early peak or late plateau. CONCLUSIONS: In our first decade of laparoscopic PEH repair, no mesh crural reinforcement was used, and no patient had a Collis gastroplasty. Evolution in the technique of laparoscopic PEH repair during the subsequent decade has reduced the hernia recurrence rate to that seen with an open approach. Reduced morbidity and shorter hospital stay make laparoscopy the preferred approach, but continued efforts to reduce hernia recurrence are warranted.