Preoperative stricture length measurement does not predict postoperative outcomes in robotic ureteral reconstructive surgery.

PURPOSE: We sought to determine whether preoperative stricture length measurement affected the choice of procedure performed, its correlation to intraoperative stricture length, and postoperative outcomes. METHODS: The Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database was queried for patients undergoing robotic ureteral reconstructive surgery from 2013 to 2021 who had surgical stricture length measurement. From this cohort, we identified patients with and without preoperative stricture length measurement via retrograde pyelogram or antegrade nephrostogram. Outcomes evaluated included intraoperative complications, 30-day complications greater than Clavien-Dindo grade II, hardware-free status, and need for additional procedures. RESULTS: Of 153 patients with surgical stricture length measurements, 102 (66.7%) had preoperative radiographic measurement. No repair type was more likely to have preoperative measurement. The Pearson correlation coefficient between surgical and radiographic stricture length measurements was + 0.79. The average surgical measurement was 0.71 cm (± 1.52) longer than radiographic assessment. Those with preoperative imaging waited on average 5.0 months longer for surgery, but this finding was not statistically significant (p = 0.18). There was no statistically significant difference in intraoperative complications, 30-day complication rates, hardware-free status at last follow-up, or need for additional procedures between patients with and without preoperative measurement. The only significant predictive factor was preoperative stricture length on 30-day postoperative complications. CONCLUSIONS: Despite relatively high prevalence of preoperative radiographic stricture length measurement, there are few measures where it offers clinically meaningful diagnostic information towards the definitive surgical management of ureteral stricture disease.

Partial or radical nephrectomy for complex renal mass: a comparative analysis of oncological outcomes and complications from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group.

PURPOSE: To compare outcomes of robotic-assisted partial nephrectomy (RAPN) and minimally invasive radical nephrectomy (MIS-RN) for complex renal masses (CRM). METHODS: We conducted a retrospective multicenter analysis of CRM patients who underwent MIS-RN and RAPN. CRM was defined as RENAL score 10-12. Primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS), recurrence, and complications. Multivariable analysis (MVA) and Kaplan-Meier Analysis (KMA) were used to analyze functional and survival outcomes for RN vs. PN by pathological stage. RESULTS: 926 patients were analyzed (MIS-RN = 437/RAPN = 489; median follow-up 24.0 months). MVA demonstrated lack of transfusion (HR = 1.63, p = 0.005), low-grade (HR = 1.18, p = 0.018) and smaller tumor size (HR = 1.05, p < 0.001) were associated with OS. Younger age (HR = 1.01, p = 0.017), high-grade (HR = 1.18, p = 0.017), smaller tumor size (HR = 1.05, p < 0.001), and lack of transfusion (HR = 1.39, p = 0.038) were associated with CSS. Increasing tumor size (HR = 1.18, p < 0.001), high-grade (HR = 3.21, p < 0.001), and increasing age (HR = 1.02, p = 0.009) were independent risk factors for recurrence. Type of surgery was not associated with major complications (p = 0.094). For KMA of MIS-RN vs. RAPN for pT1, pT2 and pT3, 5-year OS was 85% vs. 88% (p = 0.078); 82% vs. 80% (p = 0.442) and 84% vs. 83% (p = 0.863), respectively. 5-year CSS was 98% for both procedures (p = 0.473); 94% vs. 92% (p = 0.735) and 91% vs. 90% (p = 0.581). 5-year non-CSS was 87% vs. 93% (p = 0.107); 87% for pT2 (p = 0.485) and 92% for pT3 for both procedures (p = 0.403). CONCLUSION: RAPN in CRM is not associated with increased risk of complications or worsened oncological outcomes when compared to MIS-RN and may be preferred when clinically indicated.

Outcomes of Lymph Node Dissection in Nephroureterectomy in the Treatment of Upper Tract Urothelial Carcinoma: Analysis of the ROBUUST Registry.

PURPOSE: We sought to evaluate outcomes of lymph node dissection (LND) in patients with upper tract urothelial carcinoma. MATERIALS AND METHODS: We performed a multicenter retrospective analysis utilizing the ROBUUST (for RObotic surgery for Upper Tract Urothelial Cancer Study) registry for patients who did not undergo LND (pNx), LND with negative lymph nodes (pN0) and LND with positive nodes (pN+). Primary and secondary outcomes were overall survival (OS) and recurrence-free survival (RFS). Multivariable analyses evaluated predictors of outcomes and pathological node positivity. Kaplan-Meier analyses (KMAs) compared survival outcomes. RESULTS: A total of 877 patients were analyzed (LND performed in 358 [40.8%]/pN+ in 73 [8.3%]). Median nodes obtained were 10.2 for pN+ and 9.8 for pN0. Multivariable analyses noted increasing age (OR 1.1, p <0.001), pN+ (OR 3.1, p <0.001) and pathological stage pTis/3/4 (OR 3.4, p <0.001) as predictors for all-cause mortality. Clinical high-grade tumors (OR 11.74, p=0.015) and increasing tumor size (OR 1.14, p=0.001) were predictive for lymph node positivity. KMAs for pNx, pN0 and pN+ demonstrated 2-year OS of 80%, 86% and 42% (p <0.001) and 2-year RFS of 53%, 61% and 35% (p <0.001), respectively. KMAs comparing pNx, pN0 ≥10 nodes and pN0 <10 nodes showed no significant difference in 2-year OS (82% vs 85% vs 84%, p=0.6) but elicited significantly higher 2-year RFS in the pN0 ≥10 group (60% vs 74% vs 54%, p=0.043). CONCLUSIONS: LND during nephroureterectomy in patients with positive lymph nodes provides prognostic data, but is not associated with improved OS. LND yields ≥10 in patients with clinical node negative disease were associated with improved RFS. In high-grade and large tumors, lymphadenectomy should be considered.

Risk Factors for Intravesical Recurrence after Minimally Invasive Nephroureterectomy for Upper Tract Urothelial Cancer (ROBUUST Collaboration).

PURPOSE: Intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) has an incidence of approximately 20%-50%. Studies to date have been composed of mixed treatment cohorts-open, laparoscopic and robotic. The objective of this study is to assess clinicopathological risk factors for intravesical recurrence after RNU for UTUC in a completely minimally invasive cohort. MATERIALS AND METHODS: We performed a multicenter, retrospective analysis of 485 patients with UTUC without prior or concurrent bladder cancer who underwent robotic or laparoscopic RNU. Patients were selected from an international cohort of 17 institutions across the United States, Europe and Asia. Univariate and multiple Cox regression models were used to identify risk factors for bladder recurrence. RESULTS: A total of 485 (396 robotic, 89 laparoscopic) patients were included in analysis. Overall, 110 (22.7%) of patients developed IVR. The average time to recurrence was 15.2 months (SD 15.5 months). Hypertension was a significant risk factor on multiple regression (HR 1.99, CI 1.06; 3.71, p=0.030). Diagnostic ureteroscopic biopsy incurred a 50% higher chance of developing IVR (HR 1.49, CI 1.00; 2.20, p=0.048). Treatment specific risk factors included positive surgical margins (HR 3.36, CI 1.36; 8.33, p=0.009) and transurethral resection for bladder cuff management (HR 2.73, CI 1.10; 6.76, p=0.031). CONCLUSIONS: IVR after minimally invasive RNU for UTUC is a relatively common event. Risk factors include a ureteroscopic biopsy, transurethral resection of the bladder cuff, and positive surgical margins. When possible, avoidance of transurethral resection of the bladder cuff and alternative strategies for obtaining biopsy tissue sample should be considered.

Retroperitoneal versus transepritoneal robot-assisted partial nephrectomy for postero-lateral renal masses: an international multicenter analysis.

PURPOSE: To assess the outcomes of retroperitoneal robot-assisted partial nephrectomy (r-RAPN) in a large cohort of patients with postero-lateral renal masses comparing to those of transperitoneal RAPN (t-RAPN). METHODS: Patients with posterior (R.E.N.A.L. score grading P) or lateral (grading X) renal mass who underwent RAPN in six high-volume US and European centers were identified and stratified into two groups according to surgical approach: r-RAPN ("study group") and t-RAPN ("control group"). Baseline characteristics, intraoperative, and postoperative data were collected and compared. RESULTS: Overall, 447 patients were identified for the analysis. 231 (51.7%) and 216 (48.3%) patients underwent r-RAPN and t-RAPN, respectively. Baseline characteristics were not statistically significantly different between the groups. r-RAPN group reported lower median operative time (140 vs. 170 min, p < 0.001). No difference was found in ischemia time, estimated blood loss, and intraoperative complications. Overall, 47 and 54 postoperative complications were observed in r-RAPN and t-RAPN groups, respectively (20.3 vs. 25.1%, p = 0.9). 1 and 2 patients reported major complications (Clavien-Dindo ≥ III grade) in the retroperitoneal and transperitoneal groups (0.4 vs. 0.9%, p = 0.9). There was no difference in hospital re-admission rate, median length of stay, and PSM rate. Trifecta criteria were achieved in 90.3 and 89.2% of r-RAPN and t-RAPN, respectively (p = 0.7). CONCLUSION: r-RAPN and t-RAPN offer similar postoperative, functional, and oncological outcomes for patients with postero-lateral renal tumors. Our analysis suggests an advantage for r-RAPN in terms of shorter operative time, whereas it does not confirm a difference in terms of length of stay, as suggested by previous reports.

Selective clamping during robot-assisted partial nephrectomy in patients with a solitary kidney: is it safe and does it help?

OBJECTIVES: To obtain the most accurate assessment of the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN) we evaluated outcomes of this technique vs those of full clamping in patients with a solitary kidney undergoing RAPN. PATIENTS AND METHODS: Data from institutional review board-approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analysed with regard to demographics, risk factors, intra-operative complications, and postoperative outcomes using chi-squared tests, Fisher's exact tests, t-tests and Mann-Whitney U-tests. RESULTS: Our initial cohort consisted of 4112 patients, of whom 72 had undergone RAPN in a solitary kidney (51 with full clamping and 21 with selective clamping). There were no significant differences in demographics, tumour size, baseline estimated glomerular filtration rate (eGFR), or warm ischaemia time (WIT) between the groups (Table 1). Intra-operative outcomes, including estimated blood loss, operating time, and intra-operative complications were similar in the two groups. Short- and long-term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques. CONCLUSION: In a large cohort of patients with solitary kidney undergoing RAPN, selective clamping resulted in similar intra-operative and postoperative outcomes compared to full clamping and conferred no additional risk of harm. However, selective clamping did not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15 min) may have prevented identification of benefits in the selective clamping group; a similar study analysing cases with longer WIT may elucidate any beneficial effects of selective clamping.

Do patients with Stage 3-5 chronic kidney disease benefit from ischaemia-sparing techniques during partial nephrectomy?

OBJECTIVE: To analyse whether selective arterial clamping (SAC) and off-clamp (OC) techniques during robot-assisted partial nephrectomy (RPN) are associated with a renal functional benefit in patients with Stage 3-5 chronic kidney disease (CKD). PATIENTS AND METHODS: The change in estimated glomerular filtration rate (eGFR) over time was compared between 462 patients with baseline CKD 3-5 that underwent RPN with main arterial clamping (MAC) (n = 375, 81.2%), SAC (n = 48, 10.4%) or OC (n = 39, 8.4%) using a multivariable linear mixed-effects model. All follow-up eGFRs, including baseline and follow-up between 3 and 24 months, were included in the model for analysis. The median follow-up was 12.0 months (interquartile range 6.7-16.5; range 3.0-24.0 months). RESULTS: In the multivariable linear mixed-effects model adjusting for characteristics including tumour size and the R.E.N.A.L. (Radius; Exophytic/Endophytic; Nearness; Anterior/Posterior; Location) Nephrometry Score, the change in eGFR over time was not significantly different between SAC and MAC RPN (ß = -1.20, 95% confidence interval [CI] -5.45, 3.06; P = 0.582) and OC and MAC RPN (ß = -1.57, 95% CI -5.21, 2.08; P = 0.400). Only 20 (15 MAC, two SAC, three OC) patients overall had progression of their CKD stage at last follow-up. The mean ischaemia time was 17 min for MAC and 15 min for SAC. There was no benefit to SAC or OC in terms of blood loss, perioperative complications, length of stay, or surgical margins. CONCLUSION: SAC and OC techniques during RPN were not associated with benefit in preservation of eGFR in patients with baseline CKD.

Robotic partial nephrectomy vs minimally invasive radical nephrectomy for clinical T2a renal mass: a propensity score-matched comparison from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group.

OBJECTIVE: To compare outcomes of minimally invasive radical nephrectomy (MIS-RN) and robot-assisted partial nephrectomy (RAPN) in clinical T2a renal mass (cT2aRM). PATIENTS AND METHODS: Retrospective, multicentre, propensity score-matched (PSM) comparison of RAPN and MIS-RN for cT2aRM (T2aN0M0). Cohorts were PSM for age, sex, body mass index, American Society of Anesthesiologists (ASA) class, clinical tumour size, and R.E.N.A.L. score using a 2:1 ratio for RN:PN. The primary outcome was disease-free survival (DFS). Secondary outcomes included overall survival (OS), complication rates, and de novo estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 . Multivariable (MVA) and Kaplan-Meier survival analyses (KMSA) were conducted. RESULTS: In all, 648 patients (216 RAPN/432 MIS-RN) were matched. There were no significant differences in intraoperative complications (P = 0.478), Clavien-Dindo Grade ≥III complications (P = 0.063), and re-admissions (P = 0.238). The MVA revealed high ASA class (hazard ratio [HR] 2.7, P = 0.044) and sarcomatoid (HR 5.3, P = 0.001), but not surgery type (P = 0.601) to be associated with all-cause mortality. Increasing R.E.N.A.L. score (HR 1.31, P = 0.037), high tumour grade (HR 2.5, P = 0.043), and sarcomatoid (HR 2.8, P = 0.02) were associated with recurrence, but not surgery (P = 0.555). Increasing age (HR 1.1, P < 0.001) and RN (HR 3.9, P < 0.001) were predictors of de novo eGFR of <45 mL/min/1.73 m2 . Comparing RAPN and MIS-RN, KMSA revealed no significant differences for 5-year OS (76.3% vs 88.0%, P = 0.221) and 5-year DFS (78.6% vs 85.3%, P = 0.630) for pT2 RCC, and no differences for 3-year OS (P = 0.351) and 3-year DFS (P = 0.117) for pT3a upstaged RCC. The 5-year freedom from de novo eGFR of <45 mL/min/1.73 m2 was 91.6% for RAPN vs 68.9% for MIS-RN (P < 0.001). CONCLUSIONS: RAPN had similar oncological outcomes and morbidity profile as MIS-RN, while conferring functional benefit. RAPN may be considered as a first-line option for cT2aRM.

Minimally Invasive Radical Prostatectomy after Previous Bladder Outlet Surgery: A Systematic Review and Pooled Analysis of Comparative Studies.

PURPOSE: Prostate cancer surgery after previous bladder outlet surgery of benign prostatic hyperplasia is an uncommon yet challenging scenario. We performed a systematic review and pooled analysis of comparative studies on laparoscopic and robotic minimally invasive radical prostatectomy after bladder outlet surgery. MATERIALS AND METHODS: We searched the literature on PubMed®, Embase® and Web of Science™ up to February 2019 according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to identify eligible studies. Surgical, oncologic and functional outcomes in patients who underwent minimally invasive radical prostatectomy after bladder outlet surgery were compared to those without a history of bladder outlet surgery. Sensitivity analysis was done according to surgical technique (laparoscopic or robotic). RevMan 5.3 was used for statistical analysis. RESULTS: A total of 12 comparative studies were included in analysis. Patients who underwent minimally invasive radical prostatectomy after bladder outlet surgery were older (p ≤0.00001) and had a smaller prostate (p = 0.04) and lower prostate specific antigen (p = 0.003). The previous bladder outlet surgery group had lower odds of nerve sparing procedures, longer operative time, a higher rate of bladder neck reconstruction (each p <0.0001) and longer catheter time (p = 0.03). They were at higher risk for intraoperative (p = 0.001), overall (p <0.00001) and major complications (p = 0.0008), a higher positive surgical margin rate (p = 0.0005) and biochemical recurrence (p = 0.05). Moreover, potency (p = 0.03) and continence recovery (p = 0.007) at 12 months were lower in men with previous bladder outlet surgery. Robotic surgery seemed to offer better outcomes than laparoscopy. CONCLUSIONS: Minimally invasive radical prostatectomy after previous bladder outlet surgery represents a challenging surgical task with a higher risk of complications, and higher odds of worse functional and oncologic outcomes. Patients should be aware of these drawbacks and these factors should be considered during patient counseling. When surgery is pursued, robot-assisted radical prostatectomy should be preferred over laparoscopic radical prostatectomy since it can offer superior outcomes. The overall literature on this topic is of low quality and further efforts should be made to obtain higher levels of evidence.

The use of indocyanine green during robotic ureteroenteric reimplantation for the management of benign anastomotic strictures.

PURPOSE: We describe our technique for using intraureteral and intraurinary diversion indocyanine green (ICG) during robotic ureteroenteric reimplantation and report our outcomes. METHODS: We retrospectively reviewed eight patients who underwent ten robotic ureteroenteric reimplantations between August 2013 and July 2017. ICG was injected antegrade and/or retrograde into the lumen of the ureter, and retrograde into the lumen of the urinary diversion. All patients consented to off-label use of ICG. Postoperatively, all patients were assessed for: clinical success: the absence of flank pain; and radiological success: the absence of obstruction on renal scan and/or loopogram. RESULTS: Visualization of ICG under near-infrared fluorescence allowed for precise identification of the strictured ureter and urinary diversion, which fluoresced green; and localization the ureteroenteric stricture margins, which poorly fluoresced green. The median operative time was 208 min (IQR 191-299), estimated blood loss was 125 ml (IQR 69-150), and length of stay was 6 days (IQR 1-8). Three of eight (37.5%) patients suffered a minor (Clavien ≤ 2), and 2/8 (25.0%) patients suffered a major (Clavien > 2) post-operative complication. There were no complications related to ICG use. At a median follow-up of 29 months (IQR 21-38), 8/10 (80.0%) ureteroenteric reimplantations were clinically and radiologically successful. CONCLUSIONS: Intraureteral and intraurinary diversion ICG may be utilized as a real-time contrast agent during robotic ureteroenteric reimplantation to assist with identification of the strictured ureter and urinary diversion, and delineation of the ureteroenteric stricture margins. Despite this, RUER remains a technically difficult and morbid procedure.

Hypertension and diabetes mellitus are not associated with worse renal functional outcome after partial nephrectomy in patients with normal baseline kidney function.

OBJECTIVE: To analyze the association of hypertension and/or diabetes mellitus on renal function after partial nephrectomy in patients with normal baseline kidney function. METHODS: We identified 453 patients with baseline estimated glomerular filtration rate ≥60 that underwent robotic partial nephrectomy for a cT1 renal mass from 2008 to 2014 using a multi-institutional database. The association between estimated glomerular filtration rate and time (pre-partial nephrectomy to 24 months post-partial nephrectomy) was compared between 269 (59.4%) patients with preoperative hypertension and/or diabetes mellitus and 184 (40.6%) patients with neither hypertension nor diabetes mellitus using a multivariable model adjusting for confounders. RESULTS: The estimated glomerular filtration rate significantly decreased over time for both groups compared with baseline (average units/month: 1.8974 hypertension/diabetes mellitus, 1.2163 no hypertension/diabetes mellitus; P < 0.0001), and the estimated glomerular filtration rate decrease per month reduced over time (P < 0.0001). The estimated glomerular filtration rate began to increase at approximately 12 months for the hypertension/diabetes mellitus group, and at approximately 18 months for the no hypertension/diabetes mellitus group. Although a greater initial decline in the estimated glomerular filtration rate after partial nephrectomy was observed for the hypertension/diabetes mellitus group (0.68 units/month), this was not statistically significant (P = 0.0842); and while the rate of recovery from this decline was faster for the hypertension/diabetes mellitus group, this also was not statistically significant (P = 0.0653). The predicted estimated glomerular filtration rate was similar (83 mL/min/1.73 m2 ) for both groups 24 months after partial nephrectomy. CONCLUSIONS: There seems to be no significant association between hypertension, diabetes mellitus and renal functional outcome after partial nephrectomy in patients with normal baseline glomerular filtration rate. Renal function declines after partial nephrectomy, but then it recovers, irrespective of the presence of hypertension or diabetes mellitus.

Robot-assisted partial nephrectomy for large renal masses: a multi-institutional series.

OBJECTIVES: To compare peri-operative outcomes after robot-assisted partial nephrectomy (RAPN) for cT2a (7 to <10 cm) to cT1 tumours. MATERIALS AND METHODS: Patients with a cT1a (n = 1 358, 76.4%), cT1b (n = 379, 21.3%) or cT2a (n = 41, 2.3%) renal mass were identified from a multi-institutional RAPN database. Intra- and postoperative outcomes were compared for cT2a masses vs cT1a and cT1b masses using multivariable regression models (linear, logistic, Poisson etc.), adjusting for operating surgeon and a modified R.E.N.A.L. nephrometry score that excluded the radius component. RESULTS: The median sizes for cT1a, cT1b and cT2a tumours were 2.5, 5.0 and 8.0 cm, respectively (P < 0.001) with modified R.E.N.A.L. nephrometry scores being 6.0, 6.5 and 7.0, respectively (cT1a, P < 0.001; cT1b, P = 0.105). RAPN for cT2a vs cT1a masses was associated with a 12% increase in operating time (P < 0.001), a 32% increase in estimated blood loss (P < 0.001), a 7% increase in ischaemia time (P = 0.008), a 3.93 higher odds of acute kidney injury at discharge (95% confidence interval [CI] 1.33, 8.76; P = 0.009) and a higher risk of recurrence (hazard ratio [HR] 10.9, 95% CI 1.31, 92.2; P = 0.027). RAPN for cT2a vs cT1b masses was associated with a 12% increase in blood loss (P = 0.036), a 5% increase in operating time (P = 0.062) and a marginally higher risk of recurrence (HR 11.2, 95% CI 0.77, 11.5; P = 0.059). RAPN for cT2a tumours was not associated with differences in complications (cT1a, P = 0.535; cT1b, P = 0.382), positive margins (cT1a, P = 0.972; cT1b, P = 0.681), length of stay (cT1a, P = 0.507; cT1b, P = 0.513) or renal function decline up to 24 months post-RAPN (cT1a, P = 0.124; cT1b, P = 0.467). CONCLUSION: For T2a tumours RAPN is a feasible treatment option in a select patient population when performed by experienced surgeons in institutions equipped to manage postoperative complications. Although RAPN was associated with greater blood loss and longer operating and ischaemia time in T2a tumours, it was not associated with greater complication or positive surgical margin rates compared with T1 tumours. Renal function preservation rates were equivalent for up to 24 months postoperatively; however, 12-month recurrence-free survival was significantly lower in the T2a group. Extended follow-up is required to further evaluate long-term survival.

Development and validation of surgical training tool: cystectomy assessment and surgical evaluation (CASE) for robot-assisted radical cystectomy for men.

BACKGROUND: We aimed to develop a structured scoring tool: cystectomy assessment and surgical evaluation (CASE) that objectively measures and quantifies performance during robot-assisted radical cystectomy (RARC) for men. METHODS: A multinational 10-surgeon expert panel collaborated towards development and validation of CASE. The critical steps of RARC in men were deconstructed into nine key domains, each assessed by five anchors. Content validation was done utilizing the Delphi methodology. Each anchor was assessed in terms of context, score concordance, and clarity. The content validity index (CVI) was calculated for each aspect. A CVI ≥ 0.75 represented consensus, and this statement was removed from the next round. This process was repeated until consensus was achieved for all statements. CASE was used to assess de-identified videos of RARC to determine reliability and construct validity. Linearly weighted percent agreement was used to assess inter-rater reliability (IRR). A logit model for odds ratio (OR) was used to assess construct validation. RESULTS: The expert panel reached consensus on CASE after four rounds. The final eight domains of the CASE included: pelvic lymph node dissection, development of the peri-ureteral space, lateral pelvic space, anterior rectal space, control of the vascular pedicle, anterior vesical space, control of the dorsal venous complex, and apical dissection. IRR > 0.6 was achieved for all eight domains. Experts outperformed trainees across all domains. CONCLUSION: We developed and validated a reliable structured, procedure-specific tool for objective evaluation of surgical performance during RARC. CASE may help differentiate novice from expert performances.

A Review of Buccal Mucosa Graft Ureteroplasty.

PURPOSE OF REVIEW: We review the buccal mucosa graft (BMG) ureteroplasty literature to evaluate its utility in the management of ureteral strictures, identify indications for which it is particularly useful, and highlight refinements in surgical technique. RECENT FINDINGS: Recent reports have described the efficacy of robotic BMG ureteroplasty and the utilization of near-infrared fluorescence to assist with precise identification of the ureteral stricture margins. BMG ureteroplasty is well-suited for ureteral reconstruction as it allows for minimal disruption of the delicate ureteral blood supply and facilitates a tension-free anastomosis. This technique is particularly useful in patients with long ureteral strictures not amenable to ureteroureterostomy and in patients with a recurrent ureteral stricture after a previously failed ureteral reconstruction.

African-American men with prostate cancer have larger tumor volume than Caucasian men despite no difference in serum prostate specific antigen.

INTRODUCTION: Prior studies suggest that among men with low grade prostate cancer, African Americans (AA) produce less prostate-specific antigen (PSA) than Caucasians. We investigated racial differences in PSA, PSA density (PSAD), and tumor volume among men with prostate cancer, regardless of tumor grade. These racial differences, if present, would suggest that AA men may benefit from different screening, surveillance, and treatment regiments compared to Caucasians. MATERIALS AND METHODS: We identified men from our institutional prostate cancer database that underwent radical prostatectomy between 2012 and 2015. Clinicopathologic parameters were compared by race. Multivariable linear regression was then performed to identify factors associated with PSA, PSAD, and tumor volume, adjusting for race, age, body mass index, and pathologic parameters. RESULTS: A total of 255 men were included in the analysis, including 182 (71.4%) Caucasian and 73 (28.6%) AA. PSA (10.2 versus 8.1, p = 0.13) and PSAD (0.23 versus 0.22, p = 0.73) did not differ significantly between AA and Caucasian men. In contrast, tumor volume was significantly greater in AA men (13.4 versus 9.6 grams, p = 0.01). In multivariable linear regression analysis, AA race was not associated with PSA (p = 0.80) or PSAD (p = 0.41), but was significantly associated with increased tumor volume (p < 0.01). CONCLUSIONS: AA men who underwent radical prostatectomy in this analysis had larger tumor volume than Caucasian men despite having similar PSA levels. This association suggests that prostate cancers in AA men may produce less PSA than in Caucasian men. These findings have implications for prostate cancer screening and treatment, as PSA may underestimate the presence or extent of cancer in AA men.

Robotic Ureteroplasty with Buccal Mucosa Graft for the Management of Complex Ureteral Strictures.

PURPOSE: Surgical management of proximal and mid ureteral strictures that are not amenable to primary excision and anastomosis is challenging. Although a buccal mucosa graft is commonly used during substitution urethroplasty, its use in substitution ureteroplasty is limited. We describe our technique of robotic ureteroplasty with a buccal mucosa graft to manage complex ureteral strictures and we report our outcomes. MATERIALS AND METHODS: We retrospectively reviewed the records of 12 patients who underwent robotic ureteroplasty with a buccal mucosa graft between September 2014 and June 2016. The indication for the procedure was a proximal or mid ureteral stricture not amenable to primary excision and anastomosis. The primary outcomes were clinical success, absent symptoms on ureteral pathology and radiological success, defined as absent ureteral obstruction on retrograde pyelography, renal scan and/or computerized tomography. RESULTS: Four of the 12 patients (33.3%) had a ureteropelvic junction stricture, 4 (33.3%) had a proximal stricture and 4 (33.3%) had a mid ureteral stricture. Eight of the 12 patients (66.7%) had previously undergone failed ureteral reconstruction. Median stricture length was 3 cm (range 2 to 5). Median operative time was 217 minutes (range 136 to 344) and mean estimated blood loss was 100 ml (range 50 to 200). Median length of stay was 1 day (range 1 to 6). At a median followup of 13 months (range 4 to 30) 10 of the 12 cases (83.3%) were clinically and radiologically successful. CONCLUSIONS: Robotic ureteroplasty with a buccal mucosa graft is associated with low inherent morbidity. It is an effective way to manage complex proximal and mid ureteral strictures.

Predicting Complications Following Robot-Assisted Partial Nephrectomy with the ACS NSQIP® Universal Surgical Risk Calculator.

PURPOSE: We evaluated the predictive value of the ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Program®) surgical risk calculator in a tertiary referral cohort of patients who underwent robot-assisted partial nephrectomy. MATERIALS AND METHODS: We queried our prospectively maintained, multi-institutional database of patients treated with robot-assisted partial nephrectomy and input the preoperative details of 300 randomly selected patients into the calculator. Accuracy of the calculator was assessed by the ROC AUC and the Brier score. RESULTS: The observed rate of any complication in our cohort was 14% while the mean predicted rate of any complication using the calculator was 5.42%. The observed rate of serious complications (Clavien score 3 or greater) was 3.67% compared to the predicted rate of 4.89%. Low AUC and high Brier score were calculated for any complication (0.51 and 0.1272) and serious complications (0.55 and 0.0352, respectively). The calculated AUC was low for all outcomes, including venous thromboembolism (0.67), surgical site infection (0.51) and pneumonia (0.44). CONCLUSIONS: The ACS NSQIP risk calculator poorly predicted and discriminated which patients would experience complications after robot-assisted partial nephrectomy. These findings suggest the need for a more tailored outcome prediction model to better assist urologists risk stratify patients undergoing robot-assisted partial nephrectomy and counsel them on individual surgical risks.

Development and Validation of an Objective Scoring Tool for Robot-Assisted Radical Prostatectomy: Prostatectomy Assessment and Competency Evaluation.

PURPOSE: Comprehensive training and skill acquisition by urological surgeons are vital to optimize surgical outcomes and patient safety. We sought to develop and validate PACE (Prostatectomy Assessment and Competence Evaluation), an objective and procedure specific tool to assess the quality of robot-assisted radical prostatectomy. MATERIALS AND METHODS: Development and content validation of PACE was performed by deconstructing robot-assisted radical prostatectomy into 7 key domains utilizing the Delphi methodology. Reliability and construct validation were then assessed using de-identified videos performed by practicing surgeons and fellows. Consensus for each domain was defined as achieving a content validity index of 0.75 or greater. Reliability was assessed by the intraclass correlation and construct validation using a mixed linear model accounting for multiple ratings on the same video. RESULTS: After 3 rounds consensus was reached on wording, relevance of the skills assessed and concordance between the score assigned and the skill assessed. An intraclass correlation of 0.4 or greater was achieved for all domains. The expert group outperformed trainees in all domains but reached statistical significance in bladder drop (4.5 vs 3.4, p = 0.002), preparation of the prostate (4.4 vs 3.2, p <0.0001), seminal vesicle and posterior plane dissection (8.3 vs 6.8, p = 0.03), and neurovascular bundle preservation (4.1 vs 2.4, p <0.0001). Limitations included the lack of assessment of other key skills such as communication and decision making. CONCLUSIONS: PACE is a structured, procedure specific and reliable tool that objectively measures surgical performance during robot-assisted radical prostatectomy. It can differentiate different levels of expertise and provide structured feedback to customize training and surgical quality improvement.

Robot-assisted partial nephrectomy: continued refinement of outcomes beyond the initial learning curve.

OBJECTIVES: To evaluate trends in peri-operative outcomes of 250 consecutive cases beyond the initial learning curve (LC) of robot-assisted partial nephrectomy (RAPN) among multiple surgeons. PATIENTS AND METHODS: A multi-institutional database was used to evaluate trends in patient demographics (e.g. age, gender, comorbidities), tumour characteristics (e.g. size, complexity) and peri-operative outcomes (e.g. warm ischaemia time [WIT], operating time, complications, estimated blood loss [EBL], trifecta achievement) in consecutive cases 50-300 (n = 960) from 2008 to 2016 among four experienced surgeons. Trends in outcomes were assessed using multivariable regression models adjusted for demographic and tumour-specific variables. Outcomes for cases 50-99 were compared with those for cases 250-300. RESULTS: In the study period RAPN was increasingly performed in patients with larger tumours (ß = 0.001, P = 0.048), hypertension (odds ratio [OR] 1.003; P = 0.008) diabetes (OR 1.003; P = 0.025) and previous abdominal surgery (OR 1.003; P = 0.006). Surgeon experience was associated with more trifecta achievement (OR 1.006; P < 0.001), shorter WIT (ß = -0.036, P < 0.001), less EBL (ß = -0.154, P = 0.009), fewer blood transfusions (OR 0.989, P = 0.024) and a reduced length of hospital stay (ß = -0.002, P = 0.002), but not with operating time (P = 0.243), complications (P = 0.587) or surgical margin status (P = 0.102). Tumour size and WIT in cases 50-99 vs 250-300 were 2.7 vs 3.2 cm (P = 0.001) and 21.4 vs 16.2 min (P < 0.001), respectively. CONCLUSION: Refinement of RAPN outcomes, concomitant with the treatment of a patient population with larger tumours and more comorbidities, occurs after the initial LC is reached. Although RAPN can consistently be performed safely with acceptable outcomes after a small number of cases, improvement in trifecta achievement, WIT, EBL, blood transfusions and a shorter hospitalization continues to occur up to 300 procedures.

Comparison of perioperative and functional outcomes of robotic partial nephrectomy for cT1a vs cT1b renal masses.

OBJECTIVE: To compare perioperative and functional outcomes of patients with cT1a or cT1b renal masses undergoing robotic partial nephrectomy (RPN) in a large multi-institutional study PATIENTS AND METHODS: The present retrospective Institutional Review Board-approved multi-institutional study utilised a prospectively maintained database to identify patients undergoing RPN by six surgeons for a solitary cT1a (n = 1 307) or cT1b (n = 377) renal mass from 2006 to 2016. Perioperative and renal function outcomes at discharge and at a median follow-up of 12.2 months were compared in univariable and multivariable regression analyses adjusting for surgeon performing the procedure and date of surgery. RESULTS: In univariable analysis, cT1b masses were associated with longer operative time (190.0 vs 159.0 min, P < 0.001), longer warm ischaemia time (18.8 vs 15.0 min, P < 0.001), higher estimated blood loss (150.0 vs 100.0 mL, P < 0.001), more intraoperative complications (5.6% vs 2.4%, P = 0.034), and more surgical postoperative complications (10.1% vs 5.7%, P =0.002). Results were similar in multivariable analysis with additional findings including more overall postoperative complications (odds ratio 1.55, P = 0.015) and longer length of stay (P < 0.001) associated with cT1b masses. There were no differences in the risk of progression of chronic kidney disease stage at 12.2 months, positive surgical margins, or major postoperative complications. CONCLUSIONS: Although our study shows a longer operative time, longer warm ischemia time, and higher complication rate for patients undergoing RPN for cT1b renal masses, the magnitude of these differences is small. RPN should be considered for cT1b lesions when anatomical and spatial location allow for a feasible procedure.