An Enhanced Recovery After Surgery protocol for robotic-assisted laparoscopic nephrectomies utilizing a quadratus lumborum block.

Enhanced Recovery After Surgery (ERAS) protocols have been developed in several fields to reduce hospitalization lengths and overall costs. There have also been developments in multimodal analgesia methods to curtail opioid usage after surgery. Herein, we present the results of our initiation of an ERAS protocol for robotic-assisted laparoscopic partial and radical nephrectomies, employing a quadratus lumborum (QL) regional anesthetic block. We retrospectively reviewed 614 patients in our Institutional Review Board approved database who underwent robotic-assisted laparoscopic partial or radical nephrectomies from January 2017 to February 2020. An ERAS protocol utilizing multimodal analgesia (acetaminophen and gabapentin) and a QL block was developed and introduced in February 2019. We then compared the opioid consumption and perioperative outcomes of patients before and after ERAS protocol initiation. 192 ERAS patients (February 2019 to February 2020) were compared to 422 non-ERAS patients (January 2017 to January 2019). Baseline characteristics and the proportion of preoperative opioids users were similar between the two groups. There were no statistically significant differences in surgery length, hospitalization length, or complication rates. There were statistically significant differences in our primary endpoint, opioid consumption, on post-operative days 0 (p < 0.001), 1 (p < 0.001), and 2 (p < 0.001). The total opioid requirements over the course of admission were lower in the ERAS group compared to the non-ERAS group (p = 0.03). The initiation of an ERAS protocol employing multimodal analgesia and a QL block, for patients undergoing robotic-assisted laparoscopic partial or radical nephrectomies, can decrease opioid requirements without compromising perioperative outcomes.

Implementation of a multimodal opioid-sparing enhanced recovery pathway for robotic-assisted radical prostatectomy.

The purpose of the study is to evaluate the impact of a multimodal Enhanced Recovery After Surgery (ERAS) protocol on perioperative opioid consumption and hospital length of stay (LOS) after robotic-assisted radical prostatectomy (RARP). We compared the first 176 patients enrolled in the protocol (ERAS group) with the previous 176 patients (non-ERAS group) at a single quaternary institution from December 2017 to June 2019. The ERAS protocol included a multimodal opioid-sparing regimen utilizing acetaminophen, gabapentin, celecoxib, and liposomal bupivacaine. Demographic data, co-morbidities, post-operative pain scores, post-operative opiate consumption measured by morphine milligram equivalents (MME), operating time, and LOS were collected. The two groups were compared using chi-squared, Fisher exact, or Student t tests as appropriate. Multivariable logistic regression analysis was performed to identify predictors of prolonged LOS (> 1 day). The ERAS and non-ERAS groups were equivalent in terms of baseline characteristics and pathological data. The ERAS group had lower post-operative pain scores, post-operative opiate consumption (MME 15 vs. 46, p < 0.01), and LOS (1.2 vs. 1.7 days, p < 0.01) compared to the non-ERAS group. Only 22% in the ERAS cohort had a prolonged LOS compared to 39% of the non-ERAS group (p < 0.01). The ERAS protocol was a negative predictor of prolonged LOS on multivariable logistic regression analysis (odds ratio 0.39, 95% confidence interval 0.22-0.70, p < 0.01). A limitation of this study is its single-center retrospective design. The implementation of a multimodal opioid-sparing ERAS protocol was associated with improved pain control, reduced perioperative opioid usage, and shorter LOS after RARP.

Tri-tubular penile fracture: A case of complete rupture of urethra and bilateral corpus cavernosa.

INTRODUCTION: Tri-tubular penile fracture is a very rare subset of penile fractures, typically due to high-energy trauma to the erect penis. CASE PRESENTATION: A 26-year-old healthy man presents with a triad of audible crack, immediate detumescence, and hematoma formation, following blunt trauma sustained during vaginal sexual intercourse. A diagnosis of penile fracture is made, with intraoperative finding of a complete traumatic transection of the urethra with total bilateral corpus cavernosa disruption. Both corpora cavernosa were repaired using 2/0 polydioxanone sutures, with the dartos fascia placed in between. The urethra was repaired with interrupted 5/0 polyglactin braided absorbable suture. At 5 weeks, patient reported normal erections and sexual activity with no physical or psychological issues. The literature on management was reviewed. CONCLUSION: Current evidence of surgical management of tri-tubular penile fractures remains predominantly expert opinion, due to difficulties of conducting prospective trials for a rare condition.

Five-alpha reductase inhibitors in men undergoing active surveillance for prostate cancer: impact on treatment and reclassification after 6 years follow-up.

OBJECTIVES: To evaluate the impact of 5-alpha reductase inhibitors (5-ARIs) on definitive treatment (DT) and pathological progression (PP) in patients on active surveillance (AS) for prostate cancer. METHODS: We identified 361 consecutive patients, from an IRB-approved database, on AS for prostate cancer with minimum 2 years follow-up. Patients were grouped into two cohorts, those using 5-ARIs (5-ARI; n = 119) or not using 5-ARIs (no 5-ARI; n = 242). Primary and secondary endpoints were treatment-free survival (TFS) and PP-free survival (PPFS), which were evaluated by Kaplan-Meier analysis. Univariate and multivariable cox regression analysis were used to identify predictors for PP and DT. A p value < 0.05 was considered statistically significant. RESULTS: Baseline characteristics and the prostate biopsy rate were similar between the two groups. Median (range) follow-up was 5.7 (2.0-17.2) years. Five-year and 10-year TFS was 92% and 59% for the 5-ARI group versus 80% and 51% for the no 5-ARI group (p = 0.005), respectively. Five-year and 10-year PPFS was 77% and 41% for the 5-ARI group versus 70% and 32% for the no 5-ARI group (p = 0.04), respectively. Independent predictors for treatment and PP were not taking 5-ARIs (p = 0.005; p = 0.02), entry PSA > 2.5 ng/mL (p = 0.03; p = 0.01) and Gleason pattern 4 on initial biopsy (p < 0.001; p < 0.001), respectively. The main limitation is the retrospective study design. CONCLUSIONS: 5-ARIs reduces reclassification and cross-over to treatment in men on active surveillance for prostate cancer. Further, taking 5-ARIs was an independent predictor for prostate cancer progression and definitive treatment.

Timing, Patterns and Predictors of 90-Day Readmission Rate after Robotic Radical Cystectomy.

PURPOSE: We examine the timing, patterns and predictors of 90-day readmission after robotic radical cystectomy. MATERIALS AND METHODS: From September 2009 to March 2017, 271 consecutive patients undergoing robotic radical cystectomy with intent to cure bladder cancer (intracorporeal diversion 253, 93%) were identified from our prospectively collated institutional database. Readmission was defined as any subsequent inpatient admission or unplanned visit occurring within 90 days from discharge after the index hospitalization. Multiple readmissions were defined as 2 or more readmissions within a 90-day period. Logistic regression analysis was used to identify independent factors related to single and multiple 90-day readmissions. RESULTS: A total of 78 (28.8%) patients were readmitted at least once within 90 days after discharge, of whom 20 (25.6%) reported multiple readmissions. The cumulative duration of readmission was 6.2 (6.17) days with 6 (7.6%) patients having less than 24 hours readmission. Metabolic, infectious, genitourinary and gastrointestinal complications were identified as the primary cause of readmission in 39.5%, 23.5%, 22.3% and 17%, respectively. Fifty percent of readmissions occurred in the first 2 weeks after hospital discharge. On multivariable logistic regression analysis in-hospital infections (OR 2.85, p=0.001) were independent predictors for overall readmission. Male gender (OR 3.5, p=0.02) and in-hospital infections (OR 4.35, p=0.002) were independent predictors for multiple readmissions. CONCLUSIONS: The 90-day readmission rate following robotic radical cystectomy is significant. In-hospital infections and male gender were independent factors for readmission. Most readmissions occurred in the first 2 weeks following discharge, with metabolic derangements and infections being the most common causes.

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T3a Renal Masses: A Multicenter Analysis.

BACKGROUND: Use of partial nephrectomy (PN) in T3 renal cell carcinoma (RCC) is controversial. OBJECTIVE: To evaluate quality outcomes of robot-assisted PN (RAPN) for clinical T3a renal masses (cT3aRM). DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective multicenter analysis of patients with cT3aN0M0 RCC who underwent RAPN. INTERVENTION: RAPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was a trifecta composite outcome of negative surgical margins, warm ischemia time (WIT) ≤25 min, and no perioperative complications. The optimal outcome was defined as achieving this trifecta and ≥90% preservation of the estimated glomerular filtration rate (eGFR) and no stage upgrading of chronic kidney disease. Multivariable analysis (MVA) identified risk factors associated with lack of the optimal outcome. Kaplan-Meier analysis was conducted for survival outcomes. RESULTS AND LIMITATIONS: Analysis was conducted for 157 patients (median follow-up 26 mo). The median tumor size was 7.0 cm (interquartile range [IQR] 5.0-7.8) and the median RENAL score was 9 (IQR 8-10). Median estimated blood loss (EBL) was 242 ml (IQR 121-354) and the median WIT was 19 min (IQR 15-25). A total of 150 patients (95.5%) had negative margins. Complications were noted in 25 patients (15.9%), with 4.5% having Clavien grade 3-5 complications. The median change in eGFR was 7 ml/min/1.72 m2, with ≥90% eGFR preservation in 55.4%. The trifecta outcome was achieved for 64.3% and the optimal outcome for 37.6% of the patients. MVA revealed that greater age (odds ratio [OR] 1.06; p = 0.002), increasing RENAL score (OR 1.30; p = 0.035), and EBL >300 ml (OR 5.96, p = 0.006) were predictive of failure to achieve optimal outcome. The 5-yr recurrence-free survival, cancer-specific survival, and overall survival, were 82.1%, 93.3%, and 91.3%, respectively. Limitations include the retrospective design. CONCLUSIONS: RAPN for select cT3a renal masses is feasible and safe, with acceptable quality outcomes. Further investigation is requisite to delineate the role of RAPN in cT3a RCC. PATIENT SUMMARY: Robot-assisted partial nephrectomy in patients with stage 3a kidney cancer provided acceptable survival, functional, and morbidity outcomes in the hands of experienced surgeons, and may be considered as an option when clinically indicated.

Neoadjuvant Therapy in High-Risk Prostate Cancer.

High-risk prostate cancer (PCa) is associated with higher rates of biochemical recurrence, clinical recurrence, metastasis, and PCa-specific death, compared to low-and intermediate-risk disease. Herein, we review the various definitions of high-risk PCa, describe the rationale for neoadjuvant therapy prior to radical prostatectomy, and summarize the contemporary data on neoadjuvant therapies. Since the 1990s, several randomized trials of neoadjuvant androgen deprivation therapy (ADT) have consistently demonstrated improved pathological parameters, specifically tumor downstaging and reduced extraprostatic extension, seminal vesicle invasion, and positive surgical margins without improvements in cancer-specific or overall survival. These studies, however, were not exclusive to high-risk patients and were limited by suboptimal follow-up periods. Newer studies of neoadjuvant ADT in high-risk PCa show promising pathological and oncological outcomes. Recent level 1 data suggests neoadjuvant chemohormonal therapy (CHT) may improve longer-term survival in high-risk PCa. Immunologic neoadjuvant trials are in their infancy, and further study is required. Neoadjuvant therapies may be promising additions to the multimodal therapeutic landscape of high-risk and locally advanced PCa in the near future.

Durable biochemical response following adrenal metastasectomy for oligometastatic castrate-resistant prostate cancer.

A 77 year-old man was referred to Urology with an enlarging left adrenal mass after treatment with androgen deprivation therapy for metastatic castrate-resistant prostate cancer. He underwent a robotic-assisted left radical adrenalectomy, with pathology revealing metastatic adenocarcinoma consistent with a primary prostate adenocarcinoma. The patient had a durable oncological response to metastasectomy with no evidence of biochemical or radiological recurrence after 5 years of follow-up. Adrenal metastases from prostate cancer are extremely rare, representing only 1% of metastatic cases. Surgical resection of oligometastatic prostate cancer recurrences may be considered in select patients and may improve progression-free survival.

Retained Bullet in the Prostate Causing Lower Urinary Tract Symptoms.

A 41-year-old man presented with a 5-month history of bothersome urinary urgency and frequency. He sustained a gunshot wound to the lower abdomen 15 months prior to presentation. Digital rectal examination revealed a metallic foreign body palpable within the right lobe of the prostate, which was suggestive of a retained bullet fragment within the prostate gland. Cystourethroscopy confirmed a bullet fragment lodged within the right lateral aspect of the prostatic urethra. X-ray of the pelvis illustrated 2 radiopaque foreign bodies projecting at the level of the pubis. The patient deferred surgical retrieval and opted for pharmacological management with anti-cholinergic medication.

Upstaging to pT3a disease in patients undergoing robotic partial nephrectomy for cT1 kidney cancer: Outcomes and predictors from a multi-institutional dataset.

OBJECTIVES: Surgically treated clinical T1 (cT1) kidney cancer has in general a good prognosis, but there is a risk of upstaging that can potentially jeopardize the oncological outcomes after partial nephrectomy (PN). Aim of this study is to analyze the outcomes of robot-assisted PN (RAPN) for cT1 kidney cancer upstaged to pT3a, and to identify predictors of upstaging. MATERIAL AND METHODS: The study cohort included 1,640 cT1 patients who underwent RAPN between 2005 and 2018 at 10 academic institutions. Multivariate logistic regression model was used to assess the predictors of upstaging. Kaplan-Meier curves and multivariable Cox regression analyses were used to evaluate recurrence-free survival and overall survival. RESULTS: Overall, 74 (4%) were upstaged cases (cT1/pT3a). Upstaged patients presented larger renal tumors (3.1 vs. 2.4 cm; P = 0.001), and higher R.E.N.A.L. score (8.0 vs. 6.0; P = 0.004). cT1/pT3a group had higher rate of intraoperative complications (5 vs. 1% P = 0.032), higher pathological tumor size (3.2 vs. 2.5 cm; P < 0.001), higher rate of Fuhrman grade ≥3 (32 vs. 17%; P = 0.002), and higher number of sarcomatoid differentiation (4 vs. 1%; P = 0.008). Chronic kidney disease (CKD) stage ≥3 (OR: 2.54; P < 0.014), and clinical tumor size (OR: 1.07; P < 0.001) were independent predictors of upstaging. cT1/pT3a group had worse 2-year (94% vs. 99%) recurrence-free survival (P < 0.001). CONCLUSIONS: Upstaging to pT3a in patients with cT1 renal mass undergoing RAPN represents an uncommon event, involving less than 5% of cases. Pathologic upstaging might translate into worse oncological outcomes, and therefore strict follow-up protocols should be applied in these cases.

Minimally invasive radical nephrectomy: a contemporary review.

Minimally invasive renal surgery has revolutionized the surgical management of renal cancer since the initial report of laparoscopic nephrectomy in 1991. Laparoscopic nephrectomy became the mainstay of management in surgically resectable renal masses since the 1990s. The growing body of literature supporting nephron-sparing surgery over the last two decades has meant that minimally invasive radical nephrectomy (MI-RN) is now the preferred treatment for renal tumors not amenable to partial nephrectomy. While there is a well-described experience with complex radical nephrectomy using standard laparoscopy, robot-assisted surgery has shortened the learning curve and facilitated greater uptake of minimally invasive surgery in difficult surgical scenarios traditionally performed open surgically. Increased experience and expertise with robot-assisted renal surgery has led to expansion of the indications for MI-RN to include larger masses, locally advanced renal masses invading adjacent tissues or regional hilar/retroperitoneal lymph nodes, cytoreductive nephrectomy (CN) in metastatic disease, and concurrent venous tumor thrombectomy for renal vein or inferior vena cava (IVC) involvement. In this article, we review the various surgical techniques and adjunctive procedures associated with MI-RN.

One-Stop MRI and MRI/transrectal ultrasound fusion-guided biopsy: an expedited pathway for prostate cancer diagnosis.

PURPOSE: To assess the feasibility, safety, and outcomes of an expedited One-Stop prostate cancer (PCa) diagnostic pathway. PATIENTS AND METHODS: We identified 370 consecutive patients who underwent multiparametric magnetic resonance imaging (mpMRI) and transrectal ultrasound fusion prostate biopsy (MRI/TRUS-PBx) from our institutional review board-approved database. Patients were divided according to diagnostic pathway: One-Stop (n = 74), with mpMRI and same-day PBx, or Standard (n = 296), with mpMRI followed by a second visit for PBx. mpMRIs were performed and interpreted according to Prostate Imaging-Reporting and Data System (PI-RADS v2). Grade group ≥ 2 PCa defined clinically significant PCa (csPCa). Statistical significance was considered when p < 0.05. RESULTS: Age (66 vs 66 years, p = 0.59) and PSA density (0.1 vs 0.1 ng/mL2, p = 0.26) were not different between One-Stop vs Standard pathway, respectively. One-Stop patients lived further away from the hospital than Standard patients (163 vs 31 km; p < 0.01), and experienced shorter time from mpMRI to PBx (0 vs 7 days; p < 0.01). The number (p = 0.56) and distribution of PI-RADS lesions (p = 0.67) were not different between the groups. All procedures were completed successfully with similar perioperative complications rate (p = 0.24). For patients with PI-RADS 3-5 lesions, the csPCa detection rate (49% vs 41%, p = 0.55) was similar for One-Stop vs Standard, respectively. The negative predictive value of mpMRI (PI-RADS 1-2) for csPCa was 78% for One-Stop vs 83% for Standard (p = 0.99). On multivariate analysis, age, prostate volume and PI-RADS score (p < 0.01), but not diagnostic pathway, predicted csPCa detection. CONCLUSION: A One-Stop PCa diagnostic pathway is feasible, safe, and provides similar outcomes in a shorter time compared to the Standard two-visit diagnostic pathway.

Assessing the Impact of Time to Cystectomy for Variant Histology of Urothelial Bladder Cancer.

OBJECTIVE: To determine if the timing of radical cystectomy for variant histology of urothelial carcinoma has an impact on survival. Variant histology has been associated with aberrant behavior compared to pure urothelial carcinoma, however the timing of surgery for these patients has not been studied. MATERIALS AND METHODS: We identified 363 patients with cT2-T4N0M0 urothelial carcinoma who underwent radical cystectomy without perioperative intravesical and/or systemic therapy from 2003 to 2014. Clinicopathologic data were compared between pure urothelial carcinoma and variant histology. The time from diagnosis to radical cystectomy was analyzed as a continuous variable and dichotomized at 4-, 8-, and 12-weeks to determine impact on oncologic outcomes. RESULTS: Patients with variant histology, when compared to those with pure urothelial carcinoma, were more likely to present with extravesical disease (P <.01), be upstaged (P <.01), have lymphovascular invasion (P <.01) and have lymph node metastasis at radical cystectomy (P = .02). The median days to radical cystectomy did not differ between pure urothelial and variant histology. On multivariable analysis controlling for age, comorbidities, tumor stage, lymph node status, lymphovascular invasion, and surgical margins, every month in delay was associated with a worse overall survival for variants (HR = 1.36, P = .003). At an 8-week delay or longer, those with variant histology had a statistically worse survival (P = .03). CONCLUSION: For patients with variant histology, delays in surgery were associated with an increased risk of death.

Multiple stones in neobladder: Case report and literature review.

INTRODUCTION: Neobladder urolithiasis is a rare but important long-term complication of orthotopic urinary diversion. It may be asymptomatic and can be discovered as an incidental finding on a radiological investigation. However, when symptoms occur, they may include lower abdominal pain, dysuria, hematuria, and lower urinary tract symptoms. CASE DESCRIPTION: We report the case of a 63-year-old male patient with irritative lower urinary tract symptoms, lower abdominal fullness, urinary incontinence, fecaluria, and urinary loss from the left inguinal fold 12 years after a radical cystoprostatectomy with a orthotopic neobladder. Computed tomography scan and urethrocystography showed a distended pouch with multiple large stones, an enterovesical fistula, and neovesicocutaneous fistula. The fistulae were successfully managed conservatively with the placement of a Foley catheter. After 3 months, open cystolithotomy was performed and approximately 50 stones with dimensions varying from 5 mm to 5 cm, with a total weight of 890 g, were removed. After a 1-year follow-up, the patient did not report pain, urinary tract infections, or symptoms suggestive of fistula and imaging evaluation confirmed no recurrence of neobladder stones. CONCLUSION: Neobladder stones may present with various symptoms. Our patient had irritative lower urinary tract symptoms, lower abdominal fullness, urinary incontinence, fecaluria, and urinary loss from the left inguinal fold 12 years after a radical cystoprostatectomy with a orthotopic neobladder. Our experience demonstrates that open cystolithotomy is an effective intervention for the removal of large stones in neobladder.

Robotic intracorporeal ileal conduit: Technical aspects.

OBJECTIVE: To present a review of the technical aspects of robotic intracorporeal ileal conduit  (IC) reconstruction after robot assisted radical cystectomy (RARC). METHODS: A non-systematic review is performed in order  to summarize technical aspects on robot assisted ileal conduit procedure following radical cystectomy in patients with muscle invasive bladder cancer.  RESULTS: Radical cystectomy with pelvic lymph node dissection and urinary diversion is the gold-standard therapy for localized muscle-invasive bladder cancer. IC is the most common diversion utilized by surgeons. Minimally invasive approaches to IC were proposed with the intention of decreasing the morbidity associated to open surgery. Several oncological, and functional factors should be taken into consideration for the selection of patients undergoing this procedure together with surgeons and patients' preferences. The stoma marking of the patient is of critical importance. Identification of the ureters should be done assuring careful handling of the tissue and then isolation of the bowel segments should be performed after confirming proper length of the segment. Side to side anastomosis of the antimesenteric borders of the bowel is performed with linear staplers, and the ureteroileal anastomosis is done. Finally, the ileal conduit is positioned close to the stoma marking site and is fixed to the skin. Urinary diversion and radical cystectomy is a very morbid procedure. Mainly, complications are gastrointestinal, stoma-related, or associated to the ureter-enteric anastomosis.  CONCLUSIONS: The advantages of the robotic platform concerning postoperative outcomes may be more evident if the procedure is done in an intracorporeal fashion. Proper knowledge and mastery of the technical aspects of this procedure are critical.

ARTICULO SOLO EN INGLES. OBJETIVO: Presentar una revisión de losaspectos técnicos de la reconstrucción con conductoileal (CI) robótico intracorpóreo después de cistectomíaradical asistida por robot (CRAR).MÉTODOS: Realizamos una revisión no sistemática dela literatura para resumir los aspectos técnicos de la técnicade conducto ileal asistido por robot después de la cistectomía radical en pacientes con cáncer vesical  músculo invasivo. RESULTADOS: La cistectomía radical con linfadenectomía pélvica y derivación urinaria es el tratamiento estándar para el cáncer de vejiga músculo invasivo localizado. El conducto ileal es la derivación urinaria másfrecuentemente utilizada por los cirujanos. Los abordajes mínimamente invasivos para el CI fueron propuestos con la intención de disminuir la morbilidad asociada con la cirugía abierta. Para la selección de los pacientesque se van a someter a esta operación se deben considerar algunos factores oncológicos y funcionales, junto con las preferencias de cirujanos y pacientes. Lamarca del estoma del paciente tiene una importancia crítica. La identificación de los uréteres debe realizarse asegurando un manejo cuidadoso de los tejidos y después el aislamiento de los segmentos intestinales debe realizarse tras confirmar la adecuada longitud del segmento.Se realiza una anastomosis latero-lateral de los bordes antimesentéricos del intestino con grapadoras lineales y luego la anastomosis ureteroileal. Finalmente,el conducto ileal se posiciona cerca de la marca del estoma y se fija a la piel. La cistectomía radical con derivación urinaria es un procedimiento muy mórbido.Principalmente, las complicaciones son gastrointestinales, relacionadas con el estoma o asociadas con la anastomosis ureteroentérica. CONCLUSIONES: Las ventajas de la plataforma robótica en relación con los resultados postoperatorios puede ser más evidente si el procedimiento se realiza de forma intracorpórea. Son críticos el conocimiento adecuado y la maestría de los aspectos técnicos de la operación.

Use of indocyanine green to minimise uretero-enteric strictures after robotic radical cystectomy.

OBJECTIVE: To evaluate the impact of indocyanine green (ICG) for assessing ureteric vascularity on the rate of uretero-enteric stricture formation after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD). PATIENTS AND METHODS: We identified 179 patients undergoing RARC and ICUD between January 2014 and May 2017, and divided the patients into two groups based on the utilisation of ICG for the assessment of ureteric vascularity (non-ICG group and ICG group). We retrospectively reviewed the medical records to identify the length of ureter excised. Demographic, perioperative outcomes (including 90-day complications and readmissions), and the rate of uretero-enteric stricture were compared between the two groups. The two groups were compared using the t-test for continuous variables and the chi-squared test for categorical variables. A P < 0.05 was considered statistically significant. RESULTS: A total of 132 and 47 patients were in the non-ICG group and the ICG group, respectively. There were no differences in baseline characteristics and perioperative outcomes including operating time, estimated blood loss, and length of stay. The ICG group was associated with a greater length of ureter being excised during the uretero-enteric anastomosis and a greater proportion of patients having long segment (>5 cm) ureteric resection. The median follow-up was 14 and 12 months in the non-ICG and ICG groups, respectively. The ICG group was associated with no uretero-enteric strictures compared to a per-patient stricture rate of 10.6% and a per-ureter stricture rate of 6.6% in the non-ICG group (P = 0.020 and P = 0.013, respectively). CONCLUSION: The use of ICG fluorescence to assess distal ureteric vascularity during RARC and ICUD may reduce the risk of ischaemic uretero-enteric strictures. The technique is simple, safe, and reproducible. Larger studies with longer follow-up are needed to confirm our findings.

Contrast-Enhanced Transrectal Ultrasound for Follow-up After Focal HIFU Ablation for Prostate Cancer.

The optimal strategy for imaging after focal therapy for prostate cancer is evolving. This series is an initial report on the use of contrast-enhanced transrectal ultrasound (TRUS) in follow-up of patients after high-intensity focused ultrasound (HIFU) hemiablation for prostate cancer. In 7 patients who underwent HIFU hemiablation, contrast-enhanced TRUS findings were as follows: (1) contrast-enhanced TRUS clearly showed the HIFU ablation defect as a sharply marginated nonenhancing zone in all patients; (2) contrast-enhanced TRUS identified suspicious foci of recurrent enhancement within the ablation zone in 2 patients, facilitating image-guided prostate biopsy, which showed prostate cancer; and (3) contrast-enhanced TRUS findings correlated with multiparametric magnetic resonance imaging and biopsy histologic findings.

Assessing trends in urinary diversion after radical cystectomy for bladder cancer in the United States.

OBJECTIVES: We assessed recent trends in both urinary diversion after radical cystectomy for bladder cancer in the United States and patient- and hospital-related characteristics. We also identified variables associated with undergoing continent diversion. MATERIALS AND METHODS: We queried the National Cancer Database and identified 27,170 patients who underwent radical cystectomy with urinary diversion from 2004 to 2013. Patient demographics, socioeconomic variables, and hospital-related factors were compared between incontinent and continent diversion and trended over time. Multivariable logistic regression was used to identify variables associated with undergoing continent diversion. RESULTS: Overall, 23,224 (85.5%) and 3,946 (14.5%) patients underwent incontinent and continent diversion, respectively. Continent diversion declined from 17.2% in 2004 to 2006 to 12.1% in 2010 to 2013 (P < 0.01). When analyzing high-volume facilities, those performing ≥75% minimally invasive radical cystectomy had fewer continent diversions (10.2%) compared to centers with higher rate of open approach (19.7%), P < 0.01. Higher income, facility located in the West, academic programs, high-volume facilities, and patients traveling >60 miles for care were significantly associated with undergoing continent diversion. Rate of continent diversion has declined in most patient- and hospital-related subgroups. Compared to 2004 to 2006, patients in 2010 to 2013 were more likely to be older, have more comorbidities, and be operated on at a high-volume academic facility. CONCLUSION: The rate of continent diversion has declined to 12.1% in the United States. Hospital volume and type, patient income, distance traveled for care, and geography are significantly associated with undergoing continent diversion. Even among high-volume and academic centers, the rate of continent diversion is declining.

Primary Whole-gland Cryoablation for Prostate Cancer: Biochemical Failure and Clinical Recurrence at 5.6 Years of Follow-up.

We retrospectively evaluated complications and functional and oncologic outcomes of 94 consecutive men who underwent primary whole-gland cryoablation for localized prostate cancer (PCa) from 2002 to 2012. Kaplan-Meier and multivariable Cox regression analyses were performed using a landmark starting at 6 mo of follow-up. In total, 75% patients had D'Amico intermediate- (48%) or high- (27%) risk PCa. Median follow-up was 5.6 yr. Median time to prostate-specific antigen (PSA) nadir was 3.3 mo, and 70 patients reached PSA <0.2ng/ml postcryoablation. The 90-d high-grade (Clavien Grade IIIa) complication rate was 3%, with no rectal fistulas reported. Continence and potency rates were 96% and 11%, respectively. The 5-yr biochemical failure-free survival (PSA nadir+2ng/ml) was 81% overall and 89% for low-, 78% for intermediate-, and 80% for high-risk PCa (p=0.46). The median follow-up was 5.6 and 5.1 yr for patients without biochemical failure and with biochemical failure, respectively. The 5-yr clinical recurrence-free survival was 83% overall and 94% for low-, 84% for intermediate-, and 69% for high-risk PCa (p=0.046). Failure to reach PSA nadir <0.2ng/ml within 6 mo postcryoablation was an independent predictor for biochemical failure (p=0.006) and clinical recurrence (p=0.03). The 5-yr metastases-free survival was 95%. Main limitation is retrospective evaluation. Primary whole-gland cryoablation for PCa provides acceptable medium-term oncologic outcomes and could be an alternative for radiation therapy or radical prostatectomy. PATIENT SUMMARY: Cryoablation is a safe, minimally-invasive procedure that uses cold temperatures delivered via probes through the skin to kill prostate cancer (PCa) cells. Whole-gland cryoablation may offer an alternative treatment option to surgery and radiotherapy. We found that patients had good cancer outcomes 5 yr after whole-gland cryoablation, and those with a prostate-specific antigen value ≥0.2ng/ml within 6 mo after treatment were more likely to have PCa recurrence.