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OBJECTIVE: To describe step-by-step surgical techniques and report outcomes of the largest single-centre series of patients with distal ureteric disease exclusively treated with robot-assisted ureteric reimplantation with Boari flap (RABFUR) and psoas hitch (RAPHUR), with a minimum follow-up of 1 year and complete postoperative data. PATIENTS AND METHODS: A total of 37 patients with distal ureteric disease were treated between 2010 and 2018. Of these, 81% and 19% underwent RAPHUR and RABFUR, respectively. Intra-, peri- and postoperative outcomes were assessed. The 90-day postoperative complications were reported according to the standardised methodology proposed by the European Association of Urology Ad Hoc Panel. Functional outcomes (creatinine, estimated glomerular filtration rate [eGFR]) and postoperative symptoms (visual analogue pain scale) were assessed. RESULTS: The median operating time and blood loss were 180 min and 100 mL, respectively. There were no conversions to open surgery and no intraoperative transfusions. The median length of stay, bladder catheter indwelling time and stent removal were 4, 7 and 30 days, respectively. The median follow-up was 24 months. Overall, 10 patients (27%) had postoperative complications and of these, eight (22%) and two (5.4%) were Clavien-Dindo Grade I-II and III, respectively. At the last follow-up, the median postoperative creatinine level and eGFR were 0.9 mg/dL and 73.5 mL/min/1.73 m2 , respectively. At the last follow-up, five (13.5%) and three (8%) patients had Grade 1 hydronephrosis and mild urinary symptoms, respectively. The study limitations include its retrospective nature. CONCLUSION: In the present study, we present our RABFUR and RAPHUR techniques. We confirm the feasibility and safety profile of both approaches in patients with distal ureteric disease relying on the largest single-centre series with ≥1 year of follow-up.
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Reimplante/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Retalhos Cirúrgicos , Ureter/cirurgia , Doenças Ureterais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica , Cateteres de Demora , Creatinina/sangue , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Hidronefrose/etiologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Músculos Psoas , Reimplante/efeitos adversos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Retalhos Cirúrgicos/efeitos adversos , Fatores de Tempo , Doenças Ureterais/fisiopatologia , Cateteres Urinários , Adulto JovemRESUMO
OBJECTIVE: To determine the impact of imperative or elective indications on the perioperative, functional and oncological outcomes of patients undergoing robot-assisted partial nephrectomy. METHODS: Between June 2006 and September 2016, data of patients who underwent robot-assisted partial nephrectomy at the Onze-Lieve-Vrouwziekenhuis Hospital in Aalst, Belgium, were retrospectively reviewed from a prospectively collected database. Only patients with non-metastatic, clinical T1-T2 graded tumors were included. Perioperative, functional and oncological outcomes were recollected. A comparative analysis was carried out after dividing patients into two groups: those who underwent robot-assisted partial nephrectomy for an elective indication (group 1, n = 194), and for an imperative indication (group 2, n = 57) caused by a solitary kidney (n = 20), impaired renal function (n = 2) or both (n = 35). RESULTS: Patients in group 2 were older (74 vs 71 years, P < 0.001), and had a higher Charlson Comorbidity Index (P < 0.001) and American Society of Anesthesiologists score (P < 0.001). No differences were observed concerning laterality, sex, preoperative aspects and dimensions used for an anatomical score or clinical stage. Surgical outcomes considering estimated blood loss, surgical time, ischemia time and transfusion rate showed no significant difference between groups. The complication rate according to Clavien-Dindo showed no difference between groups (P = 0.6). No difference was found between groups with regard to percentage decrease of estimated glomerular filtration rate (7.4 vs 4.8%, P < 0.15). CONCLUSIONS: Robot-assisted partial nephrectomy can be safely and effectively carried out by experienced surgeons in a high-volume center with similar perioperative, functional and oncological outcomes for both elective or imperative indications.
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Neoplasias Renais/cirurgia , Nefrectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Bélgica , Perda Sanguínea Cirúrgica , Procedimentos Cirúrgicos Eletivos , Feminino , Taxa de Filtração Glomerular , Humanos , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Duração da Cirurgia , Período Perioperatório , Complicações Pós-Operatórias , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Resultado do TratamentoRESUMO
PURPOSE: We report a comparative analysis of robotic assisted simple prostatectomy vs holmium laser enucleation of the prostate in patients who had benign prostatic hyperplasia with a large volume prostate (greater than 100 ml). MATERIALS AND METHODS: A total of 81 patients underwent robotic assisted simple prostatectomy and 45 underwent holmium laser enucleation of the prostate in a 7-year period. Patients were preoperatively assessed with transrectal ultrasound and uroflowmetry. Functional parameters were assessed postoperatively during followup. Perioperative outcomes included operative time, postoperative hemoglobin, catheterization time and hospitalization. Complications were reported according to the Clavien-Dindo classification. RESULTS: Compared to the holmium laser enucleation group, patients treated with prostatectomy were significantly younger (median age 69 vs 74 years, p = 0.032) and less healthy (Charlson comorbidity index 2 or greater in 62% vs 29%, p = 0.0003), and had a lower rate of suprapubic catheterization (23% vs 42%, p = 0.028) and a higher preoperative I-PSS (International Prostate Symptom Score) (25 vs 21, p = 0.049). Both groups showed an improvement in the maximum flow rate (15 vs 11 ml per second, p = 0.7), and a significant reduction in post-void residual urine (-73 vs -100 ml, p = 0.4) and I-PSS (-20 vs -18, p = 0.8). Median operative time (105 vs 105 minutes, p = 0.9) and postoperative hemoglobin (13.2 vs 13.8 gm/dl, p = 0.08) were similar for robotic assisted prostatectomy and holmium laser enucleation, respectively. Median catheterization time (3 vs 2 days, p = 0.005) and median hospitalization (4 vs 2 days, p = 0.0001) were slightly shorter in the holmium laser group. Complication rates were similar with no Clavien grade greater than 3 in either group. CONCLUSIONS: Our results from a single center suggest comparable outcomes for robotic assisted simple prostatectomy and holmium laser enucleation of the prostate in patients with a large volume prostate. These findings require external validation at other high volume centers.
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Terapia a Laser , Lasers de Estado Sólido/uso terapêutico , Sintomas do Trato Urinário Inferior/cirurgia , Prostatectomia/métodos , Hiperplasia Prostática/cirurgia , Procedimentos Cirúrgicos Robóticos , Idoso , Humanos , Sintomas do Trato Urinário Inferior/etiologia , Masculino , Hiperplasia Prostática/complicações , Estudos RetrospectivosRESUMO
Introduction and Objectives: Robot-assisted simple prostatectomy (RASP) and holmium laser enucleation of the prostate (HoLEP) are both well-established, minimally invasive surgical treatment options for lower urinary tract symptoms caused by benign prostatic enlargement. We have reported the first comparative analysis of both techniques in patients with prostates of ≥200 cc. Materials and Methods: Between 2009 and 2020 a total of 53 patients with a prostate volume of ≥200 cc were surgically treated at OLV Hospital Aalst (Belgium): 31 underwent RASP and 22 underwent HoLEP. Preoperative and postoperative assessments included uroflowmetry with maximum urinary flow rate (Qmax) and postvoid residual volume (PVR), as well as the International Prostate Symptom Score (IPSS) and quality of life (IPSS-QoL). The complication rates were evaluated according to the Clavien-Dindo Classification. Results: Patients treated with RASP had significantly larger prostate volumes compared with HoLEP (median 226 cc vs 204.5 cc, p = 0.004). After a median follow-up of 14 months, both groups showed a significant improvement in the maximum flow rate (+10.60 mL/s vs +10.70 mL/s, p = 0.724) and a reduction of the IPSS score (-12.50 vs -9, p = 0.246) as well as improvement of the QoL (-3 vs -3, p = 0.880). Median operative time was similar in both groups (150 minutes vs 132.5 minutes, p = 0.665). The amount of resected tissue was lower in the RASP group (134.5 g vs 180 g, p = 0.029) and there was no significant difference in postoperative prostate-specific antigen (1.2 ng/mL vs 0.8 ng/mL, p = 0.112). Despite a similar median catheterization time (3 days vs 2 days, p = 0.748), the median hospitalization time was shorter in the HoLEP group (4 days vs 3 days, p = 0.052). Complication rates were similar in both groups (32% vs 36%, p = 0.987). Conclusion: Our results suggest similar outcomes for RASP and HoLEP in patients with very large prostates ≥200 cc. These findings will require external validation at other high-volume centers.
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Terapia a Laser , Lasers de Estado Sólido , Sintomas do Trato Urinário Inferior , Hiperplasia Prostática , Robótica , Masculino , Humanos , Próstata/cirurgia , Qualidade de Vida , Lasers de Estado Sólido/uso terapêutico , Resultado do Tratamento , Hiperplasia Prostática/cirurgia , Hiperplasia Prostática/complicações , Prostatectomia/efeitos adversos , Prostatectomia/métodos , Sintomas do Trato Urinário Inferior/cirurgia , Sintomas do Trato Urinário Inferior/complicações , Terapia a Laser/métodos , HólmioRESUMO
The Charlson comorbidity index is an outdated comorbidity assessment tool which is not disease specific and is not applicable to contemporary BCa patients.
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Cistectomia , Procedimentos Cirúrgicos Robóticos , Robótica/métodos , Neoplasias da Bexiga Urinária/cirurgia , Comorbidade , Humanos , Neoplasias da Bexiga Urinária/patologiaRESUMO
BACKGROUND: Evidence on the learning curve for robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is limited. OBJECTIVE: To assess the effect of surgical experience (SE) on perioperative and intermediate-term oncological outcomes in a large contemporary cohort of RARC patients after accounting for the impact of intersurgeon variability. DESIGN, SETTING, AND PARTICIPANTS: The study cohort included 164 patients treated with RARC and ICUD by two surgeons between 2004 and 2017 at a single European referral centre. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: For each patient, SE was defined as the total number of RARCs performed by each surgeon before the patient's operation. The relationship between SE and operative time (OT), lymph node yield (LNY), positive surgical margins (PSMs), Clavien-Dindo grade ≥2 30-d postoperative complication (CD≥2), and oncological outcomes (18-mo recurrence rate) was evaluated in multivariable linear and logistic regression models, clustering at a single-surgeon level. RESULTS AND LIMITATIONS: After adjusting for case mix, SE was associated with shorter OT (p= 0.003), lower probability of postoperative CD≥2 rates (p= 0.01), and lower 18-mo recurrence rates (p= 0.002). Conversely, SE did not predict lower PSM rates (p= 0.3) and higher LNY (p= 0.4). The relationship between SE and OT was nonlinear, with a plateau observed after 50 cases. Conversely, the relationship between SE and CD≥2 and 18-mo recurrence was linear without reaching a plateau after 88 procedures. CONCLUSIONS: SE affects perioperative and oncological outcomes after RARC with ICUD in a linear fashion, and its beneficial effect does not reach a plateau. Conversely, after 50 cases, no further improvement was observed for OT. PATIENT SUMMARY: Robot-assisted radical cystectomy with intracorporeal urinary diversion is a complex surgical procedure with a relatively long learning curve.
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Cistectomia , Procedimentos Cirúrgicos Robóticos , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária , Idoso , Competência Clínica , Cistectomia/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Perioperatório , Encaminhamento e Consulta , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Robótica , Resultado do TratamentoRESUMO
BACKGROUND: Apical dissection in robot-assisted radical prostatectomy (RARP) affects not only cancer control, but also continence recovery. OBJECTIVE: To describe a novel approach for apical dissection, the collar technique, to reduce apical positive surgical margins (PSMs). DESIGN, SETTING, AND PARTICIPANTS: A total of 189 consecutive patients (81 in the control group, 108 in the collar technique group) underwent RARP at a single center. PRIMARY OUTCOME: rates of apical PSMs; secondary outcome: urinary continence. INTERVENTION: The urethral sphincter complex is incised 2-3mm distally to the apex, to stay farther from it and reduce PSMs; the underlying smooth muscle is exposed and incised closer to the apex to preserve the maximal length of the lissosphincter. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Mann-Whitney U and chi-square tests compared median and proportions between the two groups, respectively. Univariate logistic regression tested the association between technique employed and risk of apical PSMs. RESULTS AND LIMITATIONS: Fourteen patients (7.4%) revealed apical PSMs (9.9% in the control group, 5.6% in the collar group; p=0.7). When the collar technique was used, significantly lower rates of apical PSMs occurred in pT2 disease (0% vs 7.1%; p=0.03). In case of apical tumor at preoperative magnetic resonance imaging (MRI; n=43), the collar technique determined significantly lower overall (9.7% vs 42%) and apical (3.2% vs 42%) PSMs (all p≤0.02). Continence recovery in the collar and control groups was similar. When preoperative MRI showed an apical tumor, the collar technique had a significantly lower risk of apical PSMs (odds ratio: 0.05, p=0.009). CONCLUSIONS: The collar technique reduces the rates of apical PSMs in case of apical tumor, preserving the length of the lissosphincter. PATIENT SUMMARY: We describe a novel approach for apical dissection during robot-assisted radical prostatectomy. Our technique reduces the rates of apical surgical margins in case of apical tumor at preoperative magnetic resonance imaging and leads to optimal continence recovery.
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Dissecação/métodos , Prostatectomia/instrumentação , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Incontinência Urinária/complicações , Idoso , Humanos , Imageamento por Ressonância Magnética , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Gradação de Tumores , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias , Período Pré-Operatório , Antígeno Prostático Específico/sangue , Prostatectomia/efeitos adversos , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/patologia , Recuperação de Função Fisiológica , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/tendências , Uretra/cirurgiaRESUMO
We report a case of intravesical metastasis of a clear cell renal cell carcinoma. In renal cell carcinoma 16% of patients present with metastatic disease. Renal cell carcinoma can metastasize to nearly every organ, although metastatic spread to the urinary bladder is rare, with fewer than 70 described cases. The route and pattern of metastatic spread is not yet fully understood and different pathways are suggested. Gross haematuria is the presenting symptom in the majority of cases. These intravesical metastases may be synchronous or metachronous and can be solitary or part of polymetastatic disease. No standard treatment can be suggested due to the rare nature of this phenomenon, and treatment varies from transurethral resection, partial or complete cystectomy to systemic therapy. Prognosis in patients with a solitary bladder lesion that developed metachronously is rather good, whereas poor prognosis can be expected in patients with synchronous and multiple metastases.
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OBJECTIVE: To evaluate perioperative morbidity and mortality rate, a 3-year recurrence-free survival, and cancer-specific mortality rate in patients older than 80 years undergoing robot-assisted radical cystectomy (RARC). MATERIALS AND METHODS: We retrospectively collected data of 155 consecutive patients who received RARC for muscle-invasive or high-risk nonmuscle-invasive urothelial carcinoma of the bladder between 2003 and 2014 at a high-volume robotic center. Diversion was performed intra- or extracorporeally according to the surgeon's preferences. Complications were graded according to the Clavien-Dindo system. Logistic regression analyses were used to assess the impact of age on postoperative outcomes. RESULTS: Of 155 consecutive patients, 22 (14.2%) patients were 80 years or older. Octogenarians did not significantly differ from younger patients in ASA score (p = 0.4) and Charlson comorbidity index (p = 0.4). Prevalence of any grade and high-grade complications was similar in both groups (all p ≥ 0.6). Older patients had a significantly higher pathologic tumor grade (p = 0.04) and a lower use of pelvic lymphadenectomy (p < 0.001). No perioperative mortality rate was recorded within 90 days from surgery. Elderly patients had a similar risk of 3-year oncologic recurrence after surgery compared with their younger counterparts (odds ratio [OR] 1.63; p = 0.2). Conversely, the risk of cancer-specific mortality rate was significantly higher (OR 2.78; p = 0.02). CONCLUSIONS: Patients 80 years or older undergoing RARC for bladder cancer did not have a higher risk of peri- and postoperative morbidity and mortality rate and had a similar 3-year recurrence-free survival, suggesting that RARC can be safely performed in selected elderly patients by experienced surgeons.