Evaluating post radical prostatectomy mechanisms of early continence.

BACKGROUND: To identify the periprostatic structures associated with early return of urinary continence after radical prostatectomy (RP). METHODS: We compared total continence results between four different techniques of robot-assisted radical prostatectomy (RARP). Specifically, we studied 1-week and 1-month zero-pad continence rates of anterior (n = 60), posterior (n = 59), a novel hybrid posterior-anterior (n = 12), and transvesical (n = 12) approaches of RARP. Each technique preserved a unique set of periprostatic anatomic structures, thereby, allowing evaluation of the individual impact of preservation of nerves, bladder neck, and space of Retzius with associated anterior support structures on early continence. Urethral length was preserved in all approaches. The space of Retzius was preserved in posterior and transvesical approaches, while the bladder neck was preserved in posterior and hybrid approaches. Nerve sparing was done per preoperative oncological risk. For all patients, 24-h pad usage rates and 24-h pad weights were noted at 1 week and 1 month after catheter removal. Multivariable logistic regression analysis was performed to identify predictors of early continence. Data were obtained from prospective studies conducted between 2015 and 2021. RESULTS: At 1 week, 15%, 42%, 45%, and 8% of patients undergoing anterior, posterior, hybrid, and transvesical RARP approaches, respectively, were totally continent (p = 0.003). These rates at 1 month were 35%, 66%, 64%, and 25% (p = 0.002), respectively. The transvesical approach, which preserved the space of Retzius but not the bladder neck, was associated with the poorest continence rates, while the posterior and hybrid approaches in which the bladder neck was preserved with or without space of Retzius preservation were associated with quickest urinary continence recovery. Bladder neck preservation was the only significant predictor of 1-week and 1-month total continence recovery in adjusted analysis, Odds ratios 9.06 (p = 0.001) and 5.18 (p = 0.004), respectively. CONCLUSIONS: The beneficial effect of the Retzius-sparing approach on early continence recovery maybe associated with bladder neck preservation rather than space of Retzius preservation.

Anti-Androgen Therapy Overcomes the Time Delay in Initiation of Salvage Radiation Therapy and Rescues the Oncological Outcomes in Men with Recurrent Prostate Cancer After Radical Prostatectomy: A Post Hoc Analysis of the RTOG-9601 Trial Data.

BACKGROUND: It is unknown whether the addition of anti-androgen therapy (AAT) to late salvage radiation therapy (sRT) can lead to oncological outcomes equivalent to that of early sRT in men with recurrent prostate cancer (CaP) after surgery. METHODS: Data on 670 men who participated in the Radiation Therapy Oncology Group (RTOG)-9601 trial and who experienced biochemical recurrence were extracted using the National Clinical Trials Network (NCTN) data archive platform. Patients were stratified into four treatment groups: early sRT (pre-sRT prostate-specific antigen [PSA] < 0.7 ng/mL) and late sRT (pre-sRT PSA ≥ 0.7 ng/mL) with/without concomitant AAT, based on cut-offs reported in the original trial. Time-varying Cox proportional hazards and Fine-Gray competing-risk regression analyses assessed the adjusted hazards of overall mortality, CaP-specific mortality, and metastasis among the four treatment groups. RESULTS: At 15-years (median follow-up of 14.7 years), for patients treated with early sRT, early sRT with AAT, late sRT, and late sRT with AAT, the overall mortality, CaP-specific mortality, and metastasis rates were 22.9, 22.8, 40.1, and 22.9% (log-rank p = 0.0039), 12.1, 3.9, 22.7, and 8.0% (Gray's p = 0.0004), and 18.8, 14.6, 35.9, and 19.5% (Gray's p = 0.0004), respectively. Time-varying multivariable adjusted analysis demonstrated increased hazards of overall mortality in patients receiving delayed sRT versus early sRT (hazards ratio [HR] 1.49, 95% confidence interval [CI] 1.02-2.17); however, no difference remained after the addition of concomitant AAT to late sRT (HR 0.85, 95% CI 0.55-1.32, referent early sRT). Likewise, the hazards of cancer-specific mortality and metastatic progression were worse for late sRT when compared with early sRT, but were no different after the addition of AAT to late sRT. CONCLUSIONS: Poorer outcomes associated with late sRT in men with recurrent CaP may be rescued by delivery of concomitant AAT.

Robotic Kidney Transplantation with Regional Hypothermia versus Open Kidney Transplantation for Patients with End Stage Renal Disease: An Ideal Stage 2B Study.

PURPOSE: We report on comparative effectiveness of minimally invasive versus traditional open kidney transplantation. MATERIALS AND METHODS: We undertook a prospective cohort study of 654 patients who underwent open or robotic kidney transplantation at a single tertiary care hospital between January 2013 and December 2015. Primary outcome was delayed graft function, defined as the need for dialysis within 1 week of surgery. Secondary outcomes included postoperative complications, pain, graft rejection, and graft and patient survival. Nonparsimonious propensity score and Ding-VanderWeele analytical methods were used to account for confounding bias. RESULTS: Within the 1:3 matched cohort (robotic 126, open 378; well matched with standardized mean difference ∼10%), the robotic approach was associated with lower rates of wound infections (0% vs 4%, p=0.023) and symptomatic lymphoceles (0% vs 7% at 36 months, p=0.003), as well as reduced postoperative pain, requirement for narcotic analgesia and blood loss. There were no differences between the 2 groups, robotic versus open, with respect to graft function (delayed graft function 0% vs 2.4%, p=0.081), hospital stay (median 8 days for both, p=0.647), graft rejection (16.2% vs 18.6% at 36 months, p=0.643), and graft (95.2% vs 96.3% at 36 months, p=0.266) and overall survival (94.5% vs 98.1% at 36 months, p=0.307). Ding-VanderWeele analysis suggested minimal influence of unknown confounders on study findings. CONCLUSIONS: Robotic kidney transplantation with regional hypothermia was associated with a lower rate of postoperative complications and improved patient comfort in comparison to open kidney transplantation. Graft function, and graft and overall survival were comparable between the 2 techniques.

Clonal evaluation of early onset prostate cancer by expression profiling of ERG, SPINK1, ETV1, and ETV4 on whole-mount radical prostatectomy tissue.

BACKGROUND: Expression profiles of erythroblast transformation-specific (ETS)-related gene fusions and serine protease inhibitor Kazal-type 1 (SPINK1) in early onset prostate cancer have not been thoroughly explored. METHODS: We retrieved 151 radical prostatectomy specimens from young men with prostate cancer (<55 years) and characterized the expression of ETS-related gene (ERG), SPINK1, ETS Variant 1 (ETV1), and ETV4 by dual immunohistochemistry and dual RNA in situ hybridization. Age, race, family history, preoperative prostate-specific antigen, biochemical recurrence, and pathological variables using whole-mount radical prostatectomy tissue were collected. RESULTS: A total of 313 tumor nodules from 151 men including 68 (45%) Caucasians and 61 (40%) African Americans were included in the analysis. Positive family history of prostate cancer was seen in 65 (43%) patients. Preoperative prostate-specific antigen ranged from 0.3 to 52.7 ng/mL (mean = 7.04). The follow-up period ranged from 1 to 123.7 months (mean = 30.3). Biochemical recurrence was encountered in 8 of 151 (5%). ERG overexpression was observed in 85 of 151 (56%) cases, followed by SPINK1 in 61 of 151 (40%), ETV1 in 9 of 149 (6%), and ETV4 in 4 of 141 (3%). There were 25 of 151 (17%) cases showing both ERG and SPINK1 overexpression within different regions of either the same tumor focus or different foci. Higher frequency of ERG overexpression was seen in younger patients (≤45 years old; 76% vs 49%, P = .002), Caucasian men (71% vs 41% P = .0007), organ-confined tumors (64% vs 33%, P = .0008), and tumors of Gleason Grade groups 1 and 2 (62% vs 26%, P = .009). SPINK1 overexpression was more in African American men (68% vs 26%, P = .00008), in tumors with high tumor volume (>20%) and with anterior located tumors. ETV1 and ETV4 demonstrated rare overexpression in these tumors, particularly in the higher-grade tumors. CONCLUSION: This study expands the knowledge of the clonal evolution of multifocal cancer in young patients and support differences in relation to racial background and genetics of prostate cancer.

Predicting intra-operative and postoperative consequential events using machine-learning techniques in patients undergoing robot-assisted partial nephrectomy: a Vattikuti Collective Quality Initiative database study.

OBJECTIVE: To predict intra-operative (IOEs) and postoperative events (POEs) consequential to the derailment of the ideal clinical course of patient recovery. MATERIALS AND METHODS: The Vattikuti Collective Quality Initiative is a multi-institutional dataset of patients who underwent robot-assisted partial nephectomy for kidney tumours. Machine-learning (ML) models were constructed to predict IOEs and POEs using logistic regression, random forest and neural networks. The models to predict IOEs used patient demographics and preoperative data. In addition to these, intra-operative data were used to predict POEs. Performance on the test dataset was assessed using area under the receiver-operating characteristic curve (AUC-ROC) and area under the precision-recall curve (PR-AUC). RESULTS: The rates of IOEs and POEs were 5.62% and 20.98%, respectively. Models for predicting IOEs were constructed using data from 1690 patients and 38 variables; the best model had an AUC-ROC of 0.858 (95% confidence interval [CI] 0.762, 0.936) and a PR-AUC of 0.590 (95% CI 0.400, 0.759). Models for predicting POEs were trained using data from 1406 patients and 59 variables; the best model had an AUC-ROC of 0.875 (95% CI 0.834, 0.913) and a PR-AUC 0.706 (95% CI, 0.610, 0.790). CONCLUSIONS: The performance of the ML models in the present study was encouraging. Further validation in a multi-institutional clinical setting with larger datasets would be necessary to establish their clinical value. ML models can be used to predict significant events during and after surgery with good accuracy, paving the way for application in clinical practice to predict and intervene at an opportune time to avert complications and improve patient outcomes.

Functional Recovery, Oncologic Outcomes and Postoperative Complications after Robot-Assisted Radical Prostatectomy: An Evidence-Based Analysis Comparing the Retzius Sparing and Standard Approaches.

PURPOSE: We report a 1-year update of functional urinary and sexual recovery, oncologic outcomes and postoperative complications in patients who completed a randomized controlled trial comparing posterior (Retzius sparing) with anterior robot-assisted radical prostatectomy. MATERIALS AND METHODS: A total of 120 patients with clinically low-intermediate risk prostate cancer were randomized to undergo robot-assisted radical prostatectomy via the posterior and anterior approach in 60 each. Surgery was performed by a single surgical team at an academic institution. An independent third party ascertained urinary and sexual function outcomes preoperatively, and 3, 6 and 12 months after surgery. Oncologic outcomes consisted of positive surgical margins and biochemical recurrence-free survival. Biochemical recurrence was defined as 2 postoperative prostate specific antigen values of 0.2 ng/ml or greater. RESULTS: Median age of the cohort was 61 years and median followup was 12 months. At 12 months in the anterior vs posterior prostatectomy groups there were no statistically significant differences in the urinary continence rate (0 to 1 security pad per day in 93.3% vs 98.3%, p = 0.09), 24-hour pad weight (median 12 vs 7.5 gm, p = 0.3), erection sufficient for intercourse (69.2% vs 86.5%) or postoperative Sexual Health Inventory for Men score 17 or greater (44.6% vs 44.1%). In the posterior vs anterior prostatectomy groups a nonfocal positive surgical margin was found in 11.7% vs 8.3%, biochemical recurrence-free survival probability was 0.84 vs 0.93 and postoperative complications developed in 18.3% vs 11.7%. CONCLUSIONS: Among patients with clinically low-intermediate risk prostate cancer randomized to anterior (Menon) or posterior (Bocciardi) approach robot-assisted radical prostatectomy the differences in urinary continence seen at 3 months were muted at the 12-month followup. Sexual function recovery, postoperative complication and biochemical recurrence rates were comparable 1 year postoperatively.

Intermediate-term cancer control outcomes in prostate cancer patients treated with robotic-assisted laparoscopic radical prostatectomy: a multi-institutional analysis.

PURPOSE: Cancer control outcomes following robot-assisted radical prostatectomy (RARP) for prostate cancer (PCa) remain inadequately addressed over intermediate-term (≥5-year) follow-up. We examined biochemical recurrence-free survival (BCRFS), clinical recurrence-free survival (CRFS), and cancer-specific survival (CSS) in a multi-institutional cohort of men undergoing RARP for localized PCa. MATERIALS AND METHODS: A total of 5670 PCa patients undergoing RARP ± pelvic lymph node dissection as primary treatment modality at three tertiary care centers between 2001 and 2010 were analyzed. BCRFS, CRFS, and CSS were estimated using the Kaplan-Meier method. Cox proportional hazards model tested their association with available preoperative and postoperative parameters. RESULTS: 43.6 and 15.1 % of patients had D'Amico intermediate- and high-risk disease, respectively. Over a mean (median) follow-up of 56 (50.4) months, 797 men had a BCR, 78 men had CR, and 32 men died of PCa. Actuarial BCRFS, CRFS, and CSS, respectively, were 83.3, 98.6, and 99.5 % at 5-year; 76.5, 97.5, and 98.7 % at 8-year; and 73.3, 96.7, and 98.4 % at 10-year follow-ups. Only 1.7 % of patients received any adjuvant treatment. Preoperative prostate-specific antigen (PSA) and biopsy Gleason score (GS) were independent clinical predictors of BCRFS, CRFS, and CSS, while postoperatively positive surgical margin, pathological GS, pathological stage, and lymph node invasion were significantly associated with BCR and CR (all p < 0.05). CONCLUSIONS: Cancer control outcomes of RARP appear comparable to those reported for open and laparoscopic RP in previous literature, despite low overall rate of adjuvant treatment. Disease severity and preoperative PSA may aid in risk prognostication and defining postoperative follow-up protocols.

An evaluation of the timing of surgical complications following nephrectomy: data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

PURPOSE: The rates of complications following radical/partial nephrectomy (RN/PN) are well known; however, the data regarding timing are opaque. Accordingly, we sought to assess the median time-to-event for 19 principal postoperative complications within 30 days following surgery. METHODS: Patients undergoing RN/PN were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011). Primary endpoint was time-to-complication. Secondary endpoints included length-of-stay (LOS), re-intervention, re-admission and 30-day mortality. Multivariable regression models assessed the predictors for pre-/post-discharge complications and the effect of time-to-complication on secondary outcomes. RESULTS: Overall, 3820 patients underwent nephrectomy (RN = 63.6 %). The overall complication rate was 16.8 %, and the median LOS was 4 days. The majority of major complications (88.1 %), including bleeding/transfusion, renal, septic, deep venous thrombosis or pulmonary embolism, pulmonary, cardiac and neurologic, occurred prior to discharge. Conversely, the relatively minor complications, including wound and urinary tract infections, occurred predominantly post-discharge (70.7 %). The median time to major complications was 3 versus 13 days for minor complications. In multivariable analyses, age [odds ratio (OR) 1.02, p < 0.001], American Society of Anesthesiologists score ≥ 2 (p < 0.01) and PN (p < 0.001) were predictors of pre-discharge complications, while female gender (OR 1.67, p < 0.001), hypertension (OR 1.28, p = 0.007) and diabetes (OR 1.48, p < 0.001) were predictors of post-discharge complications. Creatinine ≥ 1.2 mg/dl and hematocrit < 30 increased (p < 0.01), whereas a minimally invasive approach decreased the odds (p < 0.05) for both pre-/post-discharge complications. For a given complication, time-to-complication did not affect the odds for mortality (p = 0.343) or re-intervention (p = 0.872). CONCLUSIONS: Approximately one in six patients suffers a complication following RN/PN; major complications tend to occur early with the majority occurring pre-discharge. Knowledge regarding the timing and risk factors for complications may facilitate improved patient-physician communication, both at admission and at discharge.

Robot-assisted hepatic mobilization and control of suprahepatic infradiaphragmatic inferior vena cava for level 3 vena caval thrombectomy: An IDEAL stage 0 study.

Robot-assisted level 1/2 inferior vena caval (IVC) thrombectomy techniques have been recently described for clinical use. Following the IDEAL recommendations on safe surgical innovation, we here describe a robotic approach for level 3 IVC thrombectomy in fresh frozen cadavers (IDEAL stage 0). In all cadavers (n = 3), hepatic mobilization with control of short hepatic veins, contralateral renal vein, infrarenal IVC and suprahepatic-infradiaphragmatic IVC could be achieved successfully, without converting to open surgery. Clinical feasibility of our technique remains to be tested.

Minimally invasive renal autotransplantation.

Minimally invasive renal allotransplantation techniques have been recently described; reported benefits include reduced morbidity/complications. These benefits have been successfully adapted for minimally invasive renal autotransplantation, however, in a non-oncological setting. We, here, describe a novel alternative robot-assisted renal autotransplantation technique, utilizing GelPOINT, which by permitting ex vivo graft examination and surgery might allow further broadening of indications for minimally-invasive renal autotransplantation, to include complex oncological renal/ureteral lesions. Future studies are needed to evaluate the utility of these techniques.

Robotic renal transplantation: Current status.

INTRODUCTION: Kidney transplantation (KT) has traditionally been performed by open renal transplantation, but recently, a few groups including our own have described a minimally invasive approach to KT. We aim to discuss the current status of robotic kidney transplantation (RKT) and describe our technique of RKT with regional hypothermia. MATERIAL AND METHODS: We used the search terms "minimally invasive" OR "robotic" OR "robot assisted" AND "kidney transplantation." Papers written in English and concerning technical and/or clinical outcomes following minimally invasive kidney transplantation were selected. Three hundred and eighteen unique articles were retrieved and nine were relevant. Comparative outcomes data following RKT with regional hypothermia versus open KT (OKT) from our own group were also included. FINDINGS: Nine papers, so far, have evaluated the role of robotic approach in KT and have conclusively established the feasibility, safety, and reproducibility of RKT, although these studies have been performed by experienced robotic surgeons/teams. The contemporary published series note that rejection rates were similar in RKT and OKT patients. Mean serum creatinine at 6 months in RKT and OKT patients was equivalent, across the three series. Most of the studies also note a dramatic reduction in the wound-related complication rates. CONCLUSION: RKT appears to be a safe surgical alternative to the standard open approach of KT. RKT is associated with reduced postoperative pain, analgesic requirement, and better cosmesis. RKT, although in its infancy, appears to be associated with lower complication rates.

Robotic surgical skill acquisition: What one needs to know?

Robotic surgery has been eagerly adopted by patients and surgeons alike in the field of urology, over the last decade. However, there is a lack of standardization in training curricula and accreditation guidelines to ensure surgeon competence and patient safety. Accordingly, in this review, we aim to highlight 'who' needs to learn 'what' and 'how', to become competent in robotic surgery. We demonstrate that both novice and experienced open surgeons require supervision and mentoring during the initial phases of robotic surgery skill acquisition. The experienced open surgeons possess domain knowledge, however, need to acquire technical knowledge under supervision (either in simulated or clinical environment) to successfully transition to robotic surgery, whereas, novice surgeons need to acquire both domain as well as technical knowledge to become competent in robotic surgery. With regard to training curricula, a variety of training programs such as academic fellowships, mini-fellowships, and mentored skill courses exist, and cater to the needs and expectations of postgraduate surgeons adequately. Fellowships provide the most comprehensive training, however, may not be suitable to all surgeon-learners secondary to the long-term time commitment. For these surgeon-learners short-term courses such as the mini-fellowships or mentored skill courses might be more apt. Lastly, with regards to credentialing uniformity in criteria regarding accreditation is lacking but earnest efforts are underway. Currently, accreditation for competence in robotic surgery is institutional specific.

Robotic kidney transplantation with intraoperative regional hypothermia.

OBJECTIVE: To describe a novel and reproducible technique of robotic kidney transplantation (RKT) that requires no repositioning, and permits intraoperative regional hypothermia. PATIENTS AND METHODS: A GelPOINT™ (Applied Medical, Santa Ranchero, CA, USA) access port was used for delivery of ice-slush and introduction of the graft kidney. The new RKT technique using ice-slush has been performed in 39 patients. RESULTS: At a mean follow-up of 3 months all of the grafts functioned. There was a marked reduction in pain and analgesic requirement compared with patients undergoing open KT, with a propensity towards quicker graft recovery and lower complication rate. CONCLUSION: RKT has been shown to be safe and feasible in patients undergoing living-donor related KT. A prospective trial is underway to assess outcomes definitively.

Bimanual examination of the retrieved specimen and regional hypothermia during robot-assisted radical prostatectomy: a novel technique for reducing positive surgical margin and achieving pelvic cooling.

OBJECTIVE: To describe a novel method of achieving pelvic hypothermia during robot-assisted radical prostatectomy (RARP) and a modification of technique allowing immediate organ retrieval for intraoperative examination and targeted frozen-section biopsies. PATIENTS AND METHODS: Intracorporeal cooling and extraction (ICE) consists of a modification of the standard RARP technique with the use of the GelPOINT™ (Applied Medical, Rancho Santa Margarita, CA, USA), a hand access platform, which allows for delivery of ice-slush and rapid specimen extraction without compromising pneumoperitoneum. RESULTS: The ICE technique reproducibly achieves a temperature of 15 °C in the pelvic cavity with no obvious body temperature change. Adopting this technique during RARP, there was an absolute risk reduction by 26.6% in positive surgical margin rate in patients with pT3a disease when compared with similar patients undergoing conventional RARP (P = 0.04). CONCLUSIONS: The ICE technique eliminates the potential handicap of decreased tactile sensation for oncological margins, especially in the high-risk patients. This technique allows the surgeon to immediately examine the surgical specimen after resection, and with the aid of frozen-section pathology determine if further resection is required. A prospective trial is underway in our centre to evaluate the effects of this novel technique on postoperative outcomes.

Robot-assisted radical prostatectomy: modified ultradissection reduces pT2 positive surgical margins on the bladder neck.

The purpose of this study was to compare the positive surgical margin (PSM) rates of 2 techniques of robot-assisted radical prostatectomy (RARP) for pT2 (localized) prostate cancer. A retrospective analysis was conducted of 361 RARP cases, performed from May 2005 to September 2008 by a single surgeon (KHR) at our institution (Yonsei University College of Medicine). In the conventional technique, the bladder neck was transected first. In the modified ultradissection, the lateral border of the bladder neck was dissected and then the bladder neck was transected while the detrusor muscle of the bladder was well visualized. Perioperative characteristics and outcomes and PSM rates were analyzed retrospectively for pT2 patients (n＝217), focusing on a comparison of those undergoing conventional (n＝113) and modified ultradissection (n＝104) techniques. There was no difference between the conventional and modified ultradissection group in mean age, BMI, PSA, prostate volume, biopsy Gleason score, and D'Amico prognostic criteria distributions. The mean operative time was shorter (p＜0.001) and the estimated blood loss was less (p＜0.01) in the modified ultradissection group. The PSM rate for the bladder neck was significantly reduced by modified ultradissection, from 6.2% to 0% (p＜0.05). In conclusion, modified ultradissection reduces the PSM rate for the bladder neck.

Robotic nephrolithotomy and pyelolithotomy with utilization of the robotic ultrasound probe.

INTRODUCTION: The treatment of large renal stones in children can be challenging often requiring combination therapy and multiple procedures. The purpose of this video is to describe our technique of robotic nephrolithotomy and pyelolithotomy for complex renal stone disease in children, and to demonstrate the utility of the robotic ultrasound probe to aid with stone localization. MATERIALS AND METHODS: Robotic nephrolithotomy/pyelolithotomy was carried out in four consecutive patients. A robotic ultrasound probe (Hitachi-Aloka, Tokyo, Japan) under console surgeon control was used in all cases. RESULTS: Two patients underwent robotic pyelolithotomy, one patient underwent robotic nephrolithotomy, whilst the fourth patient underwent robotic pyelolithotomy and nephrolithotomy along with Y-V pyeloplasty for concurrent ureteropelvic junction obstruction. Mean operative time, blood loss and hospital stay was 216 minutes, 37.5 mL and 2 days, respectively. The robotic ultrasound probe aided identification of calculi within the kidney in all cases. For nephroli¬thotomy it was helpful in planning the incision for nephrotomy. After nephrotomy or pyelotomy, stones were removed using a combination of robotic Maryland forceps, fenestrated grasper or Prograsp. Antegrade nephroscopy introduced through a laparoscopic port was used in all patients for confirmation of residual stone status. Two patients did not require a ureteral stent in the post-operative period. One patient had a minor complication (Clavien Grade 2 - dislodged malecot catheter). All patients were stone free at last follow-up. CONCLUSIONS: Robotic nephrolithotomy and pyelolithotomy with utilization of the robotic ultrasound probe offers a one-stop solution for complex renal stones with excellent stone-free rates.

Role of robot-assisted radical prostatectomy in the management of high-risk prostate cancer.

We aimed to evaluate the role of robot-assisted radical prostatectomy (RARP) in the management of high-risk prostate cancer (PCa), with a focus on oncological, functional and perioperative outcomes. Further, we also aimed to briefly describe our novel modification to conventional RARP that allows immediate organ retrieval and examination for intra-operative surgical margin assessment. A literature search of PubMed was performed for articles on the management of high-risk PCa. Papers written in English and concerning clinical outcomes following RARP for locally advanced and high-risk PCa were selected. Outcomes data from our own center were also included. A total of 10 contemporary series were evaluated. Biopsy Gleason score ≥ 8 was the most common cause for classification of patients into the high-risk PCa group. Biochemical failure rate, in the few series that looked at long-term follow-up, varied from 9% to 26% at 1 year. The positive surgical margin rate varied from 12% to 53.3%. Urinary continence rates varied from 78% to 92% at 1 year. The overall complication rates varied from 2.4% to 30%, with anastomotic leak and lymphocele being the most common complications. Long-term data on oncological control following RARP in high-risk patients is lacking. Short-term oncological outcomes and functional outcomes are equivalent to open radical prostatectomy (RP). Safety outcomes are better in patients undergoing RARP when compared with open RP. Improved tools for predicting the presence of organ-confined disease (OCD) are available. High-risk patients with OCD would be ideal candidates for RARP and would benefit most from surgery alone.

Successful robotic kidney transplantation for surgeons with no experience in minimally invasive surgery: a single institution experience.

BACKGROUND: Robotic kidney transplantation (RKT) is a novel and welcomed innovation yielding good surgical outcomes. However, data on the feasibility and safety of performing RKT by surgeons with a lack of prior minimally invasive surgery (MIS) experience are limited. The authors aimed to evaluate the surgical and functional results of RKT and present the learning curves (LC) of RKT by a single surgeon with no prior experience in MIS. MATERIALS AND METHODS: This was a retrospective study of all RKT performed between November 2019 and April 2023 at Severance Hospital in Seoul, South Korea. The authors analyzed surgical and functional outcomes, as well as complication rates of RKT in comparison to open kidney transplantation (OKT). The authors evaluated LCs using the cumulative summation method to describe the number of cases associated with the competency of a single surgeon. RESULTS: A total of 50 patients who underwent RKT and 104 patients who underwent OKT were included in this study. In RKT group, the median surgical console time was 193 min (interquartile range, 172-222) and the median vascular anastomoses time was 38 min (35-44). Total operation time was 323 min (290-371) and rewarming time was 62.5 min (56.0-70.0) in RKT group compared to 210 min (190-239) and 25 min (21-30), respectively, in OKT group. Despite extended surgical durations with a robotic technique, both groups had comparable intraoperative and postoperative outcomes, as well as renal function. Estimated blood loss and post-transplant hospital stays were significantly lower in RKT group than in OKT group. LC analysis of RKT by the single surgeon revealed that surgical competence was achieved after 15 cases. CONCLUSION: Even if surgeons do not have prior experience with MIS, they can rapidly overcome the LC and safely perform RKT with adequate preparation and acquisition of basic robotic surgical techniques.

Intermediate-Term Oncologic Outcome Assessment for Robot-Assisted Radical Prostatectomy: Comparing Retzius-Sparing with Standard Approach in a Randomized Control Cohort.

Introduction: Retzius-sparing prostatectomy was promoted with the early continence result. The long-term oncologic outcome is still unknown. In this study, we aimed to compare the intermediate-term oncologic outcomes of these two approaches in patients' cohort who were treated as part of a randomized controlled trial. Methods: A total of 120 patients were previously randomized equally to receive Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RS-RARP) vs standard robot-assisted laparoscopic radical prostatectomy (S-RARP) between January 2015 and April 2016. Baseline, surgical, and pathologic characteristics as well as oncologic outcomes were assessed. The analysis was done based on the treatment received. Result: Sixty-three patients underwent S-RARP, whereas 57 patients underwent RS-RARP. There was no statistically significant difference in the baseline nor surgical characteristics. The median follow-up was 71.24 (interquartile range: 59.75-75.75) months. There were more pathologic T3 diseases in RS-RARP. There was no significant difference in the positive margin status nor in the biochemical recurrence (BCR) rate among both groups. After S-RARP and RS-RARP, 6 and 10 patients had BCR, and the 5 years BCR-free survival was 91% and 85%, respectively (p = 0.21). Conclusion: In this cohort, there was no difference in BCR in the patients who received either technique. Further multi-institutional studies with a larger sample size and longer follow-up are required.

Prostate Specific Antigen Screening on a Nationwide Level: Featuring the Contribution of Race and Life Expectancy in Decision Making.

BACKGROUND: Estimation of life expectancy (LE) is important for the relative benefit of prostate specific antigen (PSA) screening. Limited data exists regarding screening for Black men with extended LE. The aim of the current study was to assess temporal trends in screening in United States (US) Black men with limited vs. extended LE, using a nationally representative dataset. MATERIALS AND METHODS: Using the National Health Institution Survey (NHIS) 2000 to 2018, men aged ≥40 without prior history of prostate cancer (PCa) who underwent PSA screening in the last 12 months were stratified into limited LE (ie, LE <15 years) and extended LE (ie, LE≥15 years) using the validated Schonberg index. LE-stratified temporal trends in PSA screening were analyzed for all men, and then in Black men. Weighted multivariable analyses and dominance analyses identified the predictors of PSA screening. RESULTS: PSA screening declined over the study period both for all eligible men with limited and extended LE, particularly between NHIS 2008 and 2013 (27.9%-20.7% in the extended). Screening increased significantly in Black men with extended LE (17.6% in 2010-25.7% in 2018). However, LE was not an independent predictor of screening in the Black cohort. Prior recipient of colonoscopy (55%-57%) and visit to health care provider (24%-32%) were the most important determinants for screening. CONCLUSION: For US men with extended LE, only 1 in 4 receive PSA screening, with a decline over the study-period. Screening rates increased for Black men. However, these changes were not driven by LE consideration itself, but participation in other screenings and access to a provider.