Incidence, Predictive Factors and Preventive Measures for Inguinal Hernia following Robotic and Laparoscopic Radical Prostatectomy: A Systematic Review.

PURPOSE: Inguinal hernia is a known sequel of radical prostatectomy which contributes to patient morbidity and health care expenditure. In this systematic review we evaluated the incidence of inguinal hernia associated with minimally invasive radical prostatectomy, in addition to predictive factors and preventive measures. MATERIALS AND METHODS: We searched PubMed® and Embase® between 2000 and February 2018 using the search terms inguinal hernia and radical prostatectomy. RESULTS: In concordance with search terms and selection criteria we identified a total of 155 reports with 27 studies eligible for inclusion. Collated results demonstrated a variable prevalence of inguinal hernia after laparoscopic radical prostatectomy and robotic assisted radical prostatectomy ranging from 4.3% to 8.3% and from 3% to 19.4 %, respectively. There was a higher mean prevalence of inguinal hernia after robotic assisted prostatectomy. Factors predicting inguinal hernia following minimally invasive radical prostatectomy included low body mass index, poor stream and straining prior to prostatectomy detected on symptom score instruments, a patent processus vaginalis or an intraoperative incidental inguinal hernia. Herniotomy or herniorrhaphy with onlay mesh repair was the most commonly reported intraoperative repair technique at the time of minimally invasive radical prostatectomy. Recurrence of repaired incidental hernia is rare. CONCLUSIONS: Inguinal hernia is common after minimally invasive radical prostatectomy. There is a lack of high level evidence to clarify risk factors and preventive strategies for inguinal hernia after minimally invasive radical prostatectomy. There is a justification for randomized controlled trials to further evaluate this under recognized clinical problem.

Robotic-Assisted Bladder Diverticulectomy: Indications, Technique, and Outcomes-A Case Series.

Purpose: This case series describes the experiences and outcomes of multiple Australian surgeons performing robotic-assisted bladder diverticulectomy (RABD), highlighting the procedural effectiveness and safety, for both benign and malignant indications for diverticulectomy. Methods: Outcomes were analyzed from 13 experienced Australian urologists who performed RABD between 2016 and 2023. Retrospective analysis was performed on prospectively collected data, which included patient demographics, diverticulum characteristics, surgical approaches, and post-operative outcomes. Surgical techniques included the extravesical and intravesical approaches, with the focus on maintaining oncological principles in cases of malignancy. Results: A total of 28 patients underwent RABD, with the majority being male and a mean age of 63.9 years. All surgeons utilized a four-port transperitoneal approach and opted for the extravesical dissection of the diverticular neck; one case utilized both an extravesical and a trans-diverticular approach. Functional outcomes demonstrated symptomatic resolution in patients with nonmalignant diverticula, whereas oncological outcomes indicated clear margins in 90% of malignant cases. The average length of the procedure was 106 minutes, with minimal blood loss and a mean hospital stay of 2.67 days. Early complications occurred in 14% with the majority Clavien-Dindo grade II. Conclusion: Robotic bladder diverticulectomy, predominantly via the transperitoneal extravesical approach, has emerged as a safe, effective, and reliable surgical intervention for both malignant and nonmalignant bladder diverticula. The consistent surgical approach and excellent outcomes demonstrated in this case series reinforce the procedure's potential as a safe option, even in the setting of malignancy within a diverticulum.

A Chance Finding of High Grade Prostate Cancer in a 35-Year-Old Male - A Case Report and Outcomes of Robotic Radical Prostatectomy in Young Men with Prostate Cancer.

Background: Prostate cancer is often considered a disease of older men and this indeed fits with its peak incidence between 65-79 years of age. Reports of prostate cancer in men younger than 40 years of age and the outcomes of this age group following treatment are few in the literature. Here, we present the case of an unusual diagnosis of high grade prostate cancer in a very young man and outline early outcomes following treatment with robotic-assisted radical prostatectomy. Case Presentation: A 35-year-old male, intermittently taking finasteride for hair loss, was found to have an elevated prostate-specific antigen (PSA) of 12.5ng/mL leading to an incidental diagnosis of high grade prostate cancer. Targeted trans-perineal prostate biopsy found Gleason 4+5=9 acinar adenocarcinoma, without cribriform architecture but with features suspicious for extracapsular extension. Robotic radical prostatectomy with bilateral pelvic lymph node dissection was performed and found Gleason 4+5=9 adenocarcinoma with focal cribriform architecture, extra prostatic extension and clear margins, stage pT3a N0 M0. PSA was undetectable at 12 months, continence was immediate, and the patient reported strong erections soon after surgery. Family history of prostate cancer and genetic testing were both negative. Conclusion: This case highlights that not all clinically significant cancers will be identified by following PSA screening guidelines starting at 50 years of age (or 40 years of age for men with a family history of prostate cancer). While high grade prostate cancer in a man less than 40 years of age is uncommon, the literature suggests the incidence is increasing. Our case alongside series in the literature indicate that these men have better functional outcomes and equal oncological outcomes with early surgical intervention for localized disease when compared to the older population.

Renal cell carcinoma: stage, grade and histology migration over the last 15 years in a large Australian surgical series.

OBJECTIVE: • To verify whether migration towards earlier-stage renal cell carcinoma (RCC), which has been observed in the USA over the last decade, also applies to Australia. PATIENTS AND METHODS: • Between January 1993 and December 2007, 547 nephrectomies performed in public and private hospitals in western Sydney were analysed from a retrospectively collected database. • Data were divided into three consecutive time groups. • Tumour-node-metastasis (TNM) stage as well as patient demographics, size, grade and histology of tumours and proportion of benign tumours were also assessed. RESULTS: • In all, 499 nephrectomies were performed for RCC. The median age was 62 years, with a male:female ratio of 1.9 : 1. Similarly sized tumours were identified in each time group [group 1 (1993-1997), 54.8 mm; group 2 (1998-2002), 52.0 mm; group 3 (2003-2007), 52.2 mm, P= 0.6]. • Pathological stage II disease decreased from 18.1 to 11.1%, but stage III disease showed an increase from 13.9 to 21.5% over that time period (P= 0.02). • The proportion of stage I and stage IV disease has remained relatively the same. There has been a statistically significant upward histological migration for the papillary subtype from 1.3 to 10.2% (P= 0.01). • There has also been an increasing representation of Fuhrman grade III tumours over time, from 17.6 to 30.8%, and a decreasing proportion of Fuhrman grade I tumours from 16.2 to 7.1% (P= 0.03). • There was a decrease in the incidence of benign tumours originally thought to be malignant on preoperative investigations, from 10% in group 1 to 4% in group 3 (P= 0.03). CONCLUSION: • The recent US phenomenon of migration towards earlier-stage, smaller RCCs as well as increased representation of benign tumours was not observed in the present study. The results of the present study, however, show an upward histological migration for papillary RCCs and an increasing representation of more aggressive Fuhrman grade III tumours.

Challenging situations in partial nephrectomy.

Although most partial nephrectomies are performed as primary procedures in the elective or semi-imperative setting on kidneys with relatively normal anatomy, this is not always the case. The indications for partial nephrectomy continue to expand and it is becoming particularly relevant in patients with single functioning kidneys, poor kidney function, anatomical anomalies and hereditary syndromes predisposing to multiple kidney cancers, such as Von Hippel-Lindau syndrome. These, along with previous abdominal surgery, pose surgical challenges. In this article we offer advice as to how to tackle these unusual situations. An ability to master the whole range of indications will allow the modern upper renal tract surgeon to offer partial nephrectomy to a wider range of patients.