Development of a patient and institutional-based model for estimation of operative times for robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

OBJECTIVES: To design a methodology to predict operative times for robot-assisted radical cystectomy (RARC) based on variation in institutional, patient, and disease characteristics to help in operating room scheduling and quality control. PATIENTS AND METHODS: The model included preoperative variables and therefore can be used for prediction of surgical times: institutional volume, age, gender, body mass index, American Society of Anesthesiologists score, history of prior surgery and radiation, clinical stage, neoadjuvant chemotherapy, type, technique of diversion, and the extent of lymph node dissection. A conditional inference tree method was used to fit a binary decision tree predicting operative time. Permutation tests were performed to determine the variables having the strongest association with surgical time. The data were split at the value of this variable resulting in the largest difference in means for the surgical time across the split. This process was repeated recursively on the resultant data sets until the permutation tests showed no significant association with operative time. RESULTS: In all, 2 134 procedures were included. The variable most strongly associated with surgical time was type of diversion, with ileal conduits being 70 min shorter (P < 0.001). Amongst patients who received neobladders, the type of lymph node dissection was also strongly associated with surgical time. Amongst ileal conduit patients, institutional surgeon volume (>66 RARCs) was important, with those with a higher volume being 55 min shorter (P < 0.001). The regression tree output was in the form of box plots that show the median and ranges of surgical times according to the patient, disease, and institutional characteristics. CONCLUSION: We developed a method to estimate operative times for RARC based on patient, disease, and institutional metrics that can help operating room scheduling for RARC.

Robot-assisted nerve-sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases.

OBJECTIVE: • To report the outcomes of 27 patients whom we performed robot-assisted radical cystoprostatectomy and cystectomy (RARC) with intracorporeal urinary diversion (Studer pouch and ileal conduit) for bladder cancer. PATIENTS AND METHODS: • Between December 2009 and December 2010, we performed RARC in 25 men (intrafascial bilateral [22], unilateral [one], non-neurovascular bundle [NVB] sparing [two]), NVB-sparing RARC with anterior pelvic exenteration in two women, bilateral extended robot-assisted pelvic lymph node dissection (RAPLND) (25), intracorporeal Studer pouch (23), ileal conduit (two), and extracorporeal Studer pouch (two) construction. • Patient demographics, operative and postoperative variables, pathological variables, complications (according to modified Clavien system) and functional outcomes were evaluated. RESULTS: • The mean (sd, range) operative duration, intraoperative estimated blood loss and mean lymph node (LN) yield were 9.9 (1.4, 7.1-12.4) h, 429 (257, 100-1200) mL and 24.8 (9.2, 8-46), respectively. • The mean (sd, range) hospital stay was 10.5 (6.8, 7-36) days, there was one perioperative death (3.7%), lodge drains were removed at a mean of 11.3 (5.6, 9-35) days and surgical margins were negative in all but one patient who had pT4b disease. • The postoperative pathological stages were: pT0 (five), pTis (one), pT1 (one), pT2a (five), pT2b (three), pT3a (six), pT3b (two), pT4a (three) and pT4b (one). • Positive LNs and incidental prostate cancer were detected in six and nine patients, respectively and at a mean follow-up of 6.3 (2.9, 1.8-11.3) months, three patients died from metastatic disease and one from cardiac disease. • According to the modified Clavien system, there were nine minor (Grade 1 and 2) and four major (Grade 3-5) complications in the perioperative (0-30 days) period; four minor and three major complications in the postoperative (31-90 days) period. Of the available 18 patients, 11 were fully continent, four had mild and two had severe day-time incontinence. CONCLUSIONS: • Bilateral NVB-sparing RARC with RAPLND and intracorporeal Studer pouch or ileal conduit reconstruction are complex procedures with acceptable morbidity, excellent short-term surgical and pathological outcomes and satisfactory functional results. • Studies with more patients and longer follow-ups are required to evaluate the feasibility of these RA totally intracorporeal complex procedures.

Incorporation of anterior rectus fascial sling into radical retropubic prostatectomy improves postoperative continence.

AIM: To determine the impact of rectus fascial sling suspension at the time of radical retropubic prostatectomy (RRP) on postoperative continence status. PATIENTS AND METHODS: A total of 86 patients underwent RRP for clinically localized prostate cancer. Out of 86 patients, a rectus fascial sling procedure was incorporated into RRP in 40 randomly selected patients (group 1). The remaining 46 patients underwent standard RRP without any suspension operation (group 2). RESULTS: The incontinence rates were 17.5 and 43.5% for groups 1 and 2, respectively (p = 0.010). Incontinence degrees for each group were statistically significant (p = 0.03). The mean time to achieve full continence was 1.4 +/- 2.2 (0-11) and 3.8 +/- 3.8 (0-12) months for groups 1 and 2, respectively (p = 0.026). CONCLUSION: Our results showed that incorporation of an anterior rectus fascial sling into RRP is a reasonable and efficient way of achieving improved rates of postoperative continence.

Management of ureteric duplications identified during robotic cystectomy and intracorporeal urinary diversion.

Ureteral duplication is rarely seen malformation that could be diagnosed during radiological imaging. Herein, we present 5 patients with ureteral duplication who underwent robotic radical cystectomy with intracorporeal urinary diversion for bladder cancer. Preoperative computerized tomography did not show presence of a ureteral duplication in any patient and all were identified intraoperatively. A Wallace type uretero-ureteral anastomosis was performed in all patients. During the follow-up period, we did not detect any ureterointestinal anastomotic strictures or complication related to the presence of a ureteral duplication following robotic cystectomy. We conclude that ureteral duplication might be missed during preoperative radiological imaging, might be a surprising and challenging issue for the robotic surgeon that could be safely managed intraoperatively.

Robotic intracorporeal urinary diversion: practical review of current surgical techniques.

In this practical review, we discuss current surgical techniques reported in the literature to perform intracorporeal urinary diversion (ICUD) after robotic radical cystectomy (RARC), emphasizing criticisms of single approaches and making comparisons with extracorporeal urinary diversion (ECUD). Although almost 97% of all RARCs use an ECUD, ICUD is gaining in popularity, in view of its potential benefits (i.e., decreased bowel exposure, etc.), although there are a few studies comparing ICUD and ECUD. Analyzing single experiences and the data from recent metanalyses, we emphasize the current critiques to ICUD, stressing particular technical details which could reduce operative time, lowering the postoperative complications rate, and improving functional outcomes. Only analysis of long-term follow-up data from large-scale homogeneous series can ascertain whether robotic intracorporeal urinary diversion is superior to other approaches.

BCG sepsis following inadvertent intravenous BCG administration for the treatment of bladder cancer can be effectively cured with anti-tuberculosis medications.

AIM: To the best of our knowledge we are presenting the very first case of inadvertent intravascular administration of BCG and its successful treatment with anti-tuberculosis medications on a patient with superficial bladder cancer. METHODS: A search of the English literature (PubMed/Medline) was performed concerning inadvertent BCG administration for bladder cancer by using the key words. RESULTS: The patient was admitted to our hospital with high fever and chills a few hours after intravascular BCG administration. Chest CT showed bilateral infiltration of the lungs. Patient was placed on anti-tuberculosis treatment including isoniazid, rifampycin, ethambutol and methylprednisolone initially; and this treatment was adjusted according to his clinical course and liver function tests. By the end of the 4th week of hospitalisation patient was responded well with normalisation of his clinical status, liver function tests and a normal chest X-ray. Thereafter, he was discharged home on isoniazid, ethambutol for 6 months, streptomycin, cycloserine-C and ofloxacin for 2 months, methylprednisolone which was stopped eventually after dose reduction. On follow-up at 6th month after discharge from the hospital, he was fully recovered with normal chest X-ray and blood tests. CONCLUSIONS: Development of severe sepsis is inevitable following inadvertent intravascular BCG administration. Therefore, urologists should warn and inform not only their patients and families but also healthcare workers such as nurses regarding the route of administration of the BCG treatment for bladder cancer. Our experience also proved that such a serious complication can be successfully treated if promptly acted.

Uroflowmetric assessment of acute effects of sildenafil on the voiding of men with erectile dysfunction and symptomatic benign prostatic hyperplasia.

PURPOSE: To evaluate the acute effects of sildenafil (50 mg) on the micturation of men with erectile dysfunction (ED) and concomitant benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS) using uroflowmetric parameters. MATERIALS AND METHODS: A total of 68 male patients randomized into two groups (36 treatment, 32 control groups) with International Prostate Symptom Score (IPSS) greater than 7 and International Index of Erectile Dysfunction-erectile function domain score lower than 26 were enrolled in the study. Patients in the treatment group received a single dose of 50 mg of oral sildenafil. Patients in the control group received no treatment. Prevoiding urine volumes determined ultrasonographically and voided urine volumes were also recorded. Statistical comparisons were made with the use of analysis of variance (ANOVA). RESULTS: Mean ages were similar between treatment and control groups (60.4 +/- 9.8 and 58.6 +/- 8.3 years, respectively, P = 0.430). In the treatment group the maximum and average flow rates increased significantly (Q (max) from 15.6 +/- 6.8 cc/s to 19.3 +/- 7.2 cc/s, P < 0.0001; Q (avg) from 7.3 +/- 3.0 cc/s to 9.1 +/- 3.0 cc/s, P < 0.0001) with sildenafil administration, while other parameters studied remained unchanged. CONCLUSION: Despite the limitations of variations of uroflowmetry, this study showed that sildenafil improves Q (max) and Q (avg) in patients suffering from ED with concomitant BPH-LUTS. Long-term studies are needed to evaluate the effects on IPSS, side effects, and drug interactions.