Impacts on functional and oncological outcomes of Robotic-assisted Radical Prostatectomy 10 years after the US Preventive Service Taskforce recommendations against PSA screening

ABSTRACT Objective: In the following years after the United States Preventive Service Task Force (USPSTF) recommendation against prostate cancer screening with PSA in 2012, several authors worldwide described an increase in higher grades and aggressive prostate tumors. In this scenario, we aim to evaluate the potential impacts of USPSTF recommendations on the functional and oncological outcomes in patients undergoing robotic-assisted radical prostatectomy (RARP) in a referral center. Material and Methods: We included 11396 patients who underwent RARP between 2008 and 2021. Each patient had at least a 12-month follow-up. The cohort was divided into two groups based on an inflection point in the outcomes at the end of 2012 and the beginning of 2013. The inflection point period was detected by Bayesian regression with multiple change points and regression with unknown breakpoints. We reported continuous variables as median and interquartile range (IQR) and categorical variables as absolute and relative percent frequencies. Results: Group 1 had 4760 patients, and Group 2 had 6636 patients, with a median follow-up of 109 and 38 months, respectively. In the final pathology, Group 2 had 9.5% increase in tumor volume, 24% increase on Gleason ≥ 4+3 (ISUP 3), and 18% increase on ≥ pT3. This translated to a 6% increase in positive surgical margins and 24% reduction in full nerve sparing in response to the worsening pathology. There was a significant decline in post-operative outcomes in Group 2, including a 12-month continence reduction of 9%, reduction in potency by 27%, and reduction of trifecta by 22%. Conclusions: The increasing number of high-risk patients has led to worse functional and oncologic outcomes. The initial rapid rise in PSM was leveled by the move towards more partial nerve sparing. Among some historical changes in prostate cancer diagnosis and management in the period of our study, the USPSTF recommendation coincided with worse outcomes of prostate cancer treatment in a population who could benefit from PSA screening at the appropriate time.

Reproducibility of a modified posterior reconstruction during robotic intracorporeal neobladder reconfiguration

ABSTRACT Objective: Robotic intracorporeal neobladder reconstruction is a complex procedure in which the approximation of the reservoir to the urethral stump can be a demanding step. The aim of the study is to evaluate the reproducibility of a modified posterior reconstruction (PR) during the reconfiguration of intracorporeal neobladder after robot assisted radical cystectomy (RARC). Materials and Methods: From July 2021 to July 2022, 35 RARC were performed, and 17 patients underwent intracorporeal neobladder reconstruction. A PR was planned in males (14). Intra- and peri-operative data were collected. Surgical technique: RARC and node dissection are performed. Afterwards, 40-cm ileal segment is isolated; the portion with the more adequate mesenteric length is brought down to the pelvis. A modified PR is performed with a double-armed barbed suture: a first layer connects the Denonvillier's fascia to the rhabdosphincter in a running fashion; the second layer is created with the other arm and approximates the posterior side of the ileal segment towards the urethral stump. In the anterior caudal part of the ileum, a 1.5-cm incision is made to realize the neobladder neck; the neovesical-urethral anastomosis is performed with a second bidirectional suture. Results: Anastomotic and PR time were 14 (range 7-20) and 5 minutes (4-8), respectively. A single Clavien IIIa complication was recorded in a patient who underwent NAC and had a C. albicans superinfection in the post-operative course. All patients were discharged with complete or acceptable bladder voiding. Twelve patients with follow-up >90-days reported a satisfying daytime continence. Conclusions: PR represents a simple technical refinement that improves neobladder-urethral anastomosis by favoring ileal approximation to the urethral stump and decreasing anastomotic tension.

Percutaneous and endoscopic combined treatment of bladder and renal lithiasis in mitrofanoff conduit

ABSTRACT Introduction and Objectives: Treatment of bulky lithiasis in continent and non-continent urine storage reservoirs has been widely described and debated (1). Less is known about the optimal treatment in patients with a Mitrofanoff conduit. If voiding in these patients is incomplete, leading to recurrent symptomatic bacteriuria, formation of large lithiasis can be a common long-term complication (2, 3). Materials and Methods: This video describes a 19-year-old woman who underwent major open surgery at the age of six, with the configuration of a continent intestinal reservoir with a Mitrofanoff conduit. In 2020, she was referred to our center with a large stone in the reservoir and a minor stone in the inferior left renal calyx. We decided to proceed using a percutaneous approach with an "endovision technique" puncture for the bladder stone, combined with a retrograde intrarenal surgery for the renal stone. The MIP System "M size" was used to perform the percutaneous procedure, thus allowing a single-step dilation. The puncture and the dilation were followed endoscopically with a flexible ureterorenoscope avoiding the use of x-rays. The procedure was carried out as follows. The first step consisted in the insertion of a hydrophilic guidewire through the Mitrofanoff conduit. A flexible ureterorenoscope was then inserted coaxial to the guidewire. The percutaneous puncture, using an 80G needle, was followed endoscopically. Two guidewires were inserted, the first as a safety guidewire and the second for the tract dilation. The "single-step" dilation technique using the MIP system was performed and followed endoscopically. For the bladder lithotripsy, a dual-action lithotripter that combines ultrasonic and mechanical energy was used. Finally, a flexible ureterorenoscope and a basket for the retrieval of a single inferior caliceal stone were used. The procedure ended after positioning a single J stent in the left kidney and a nephrostomy tube in the reservoir. Results: The operative time was 80 minutes and the fluoroscopy time was 6 seconds. Hemoglobin and creatinine serum levels remained stable after the procedure and the patient was discharged on the third post-operative day, after removing both the single J and the nephrostomy tube. Follow-up lasted 12 months, with no bladder or renal stone recurrence, maintaining good continence of the Mitrofanoff conduit. Conclusion: In patients who have undergone several major surgeries a mini-invasive approach is advisable, not only for the morbidity of an open approach, but also for the increased risk of complications while handling an intestinal reservoir. Regarding a pure endoscopic approach, the passage of a nephroscope or a cystoscope through the Mitrofanoff conduit, combined with the continuous traction during the lithotripsy, could damage and compromise its continence. For this reason, the percutaneous approach is the most suitable method in these specific and rare cases.

Step-by-step optimisation of robotic-assisted radical prostatectomy using augmented reality

ABSTRACT Introduction: Surgical training will be complemented by digitalisation, as the COVID 19 pandemic continues (1). Proximie is an augmented reality (AR) platform that can display up to 4 native camera views, with live or semi live telementoring. It can optimise ergonomics of the surgeon at the console (2), and robotic instrument orientation. We describe the utilisation of Proximie as a step-by-step guide in a robotic assisted radical prostatectomy (RARP). Surgical Technique: Author V. P. performed a transperitoneal multiport da Vinci Xi RARP with the Proximie platform: a laptop computer, multiple HD webcams, microphones and speakers. Using an HDMI cable to the Intuitive Surgical tower, output display from the console and an additional laparoscopic tower is shown. Each webcam was mounted to the side armrests of the console, directed at the surgeon's hands. An independent 'drop in' laparoscope via an additional 5mm left upper quadrant port was utilised. Observers can visualise the AR platform's recordings on a laptop and/or smartphone. A PTZ (pan-tilt-zoom) camera can capture the operating room, bedside assistant, ports and patient position. Our video demonstrates three of four camera views for posture, forearm, wrist, hand, and finger orientation, relative to the translated robotic steps. A pincer grasp of the endowrist manipulator during anastomosis allows optimal robotic wrist rotation. The second laparoscopic camera view demonstrated intracorporeal angles of robotic arm and bedside assistant's instrument position for critical steps such as nerve sparing and anastomosis (3). The console time was 100 minutes, no intraoperative complications, or delay in image transmission occurred with utilising the platform. Considerations: An AR platform can create deeper learning for RARP in real time or recorded sessions. Two-way verbal and visual communication with ability to annotate on screen, allows long distance mentoring. The platform's utility can be accessed in anywhere, to project surgeons beyond their immediate environment. This allows for democratisation of access to high volume institutions and their evolution of techniques (4), to assist patients globally. Potential developments are artificial intelligence (AI) networks analysing repository of such recorded data, to identify intraoperative hand motion and robotic instrument tracking. AR is a pertinent building block to enhance robotic training, skill dissemination, precision medicine (5) and surgery overall.

Techniques of nerve-sparing and potency outcomes following robot-assisted laparoscopic prostatectomy: [review]

PURPOSE: Nerve sparing radical prostatectomy is the gold standard for the treatment of prostate cancer. Over the past decade, more and more surgeons and patients are opting for a robot-assisted procedure. The purpose of this paper is to briefly review different techniques and outcomes of nerve sparing robot assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: We performed a MEDLINE search from 2001 to 2009 using the keywords “robotic prostatectomy”, “cavernosal nerve”, “pelvic neuroanatomy”, “potency”, “outcomes” and “comparison”. Extended search was also performed using the references from these articles. RESULTS: Several techniques of nerve sparing are available in literature for RALP, which have been described in this manuscript. These include, “the veil of Aphrodite”, “athermal retrograde neurovascular release”, “clipless antegrade nerve sparing” and “clipless cautery free technique”. The comparative and the non comparative series showing outcomes of RALP have been described in the manuscript. CONCLUSIONS: The basic principles for nerve sparing revolve around minimal traction, athermal dissection, and approaching the correct planes. It has not been documented if any one technique is better than the other. Regardless of technique, patient selection, wise clinical judgment and a careful dissection are the keys to achieve optimal oncological outcomes following RALP.