Long-Term Impact of Medicaid Expansion on Colorectal Cancer Screening in Its Targeted Population.

INTRODUCTION: Colorectal cancer screening continuously decreased its mortality and incidence. In 2010, the Affordable Care Act extended Medicaid eligibility to low-income and childless adults. Some states elected to adopt Medicaid at different times while others chose not to. Past studies on the effects of Medicaid expansion on colorectal cancer screening showed equivocal results based on short-term data following expansion. AIMS: To examine the long-term impact of Medicaid expansion on colorectal cancer screening among its targeted population at its decade mark. METHODS: Behavioral Risk Factor Surveillance System data were extracted for childless adults below 138% federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were stratified into very early expansion states, early expansion states, late expansion states, and non-expansion states. Colorectal cancer screening prevalence was determined for eligible respondents. Difference-in-differences analyses were used to examine the effect of Medicaid expansion on colorectal cancer screening in states with different expansion statuses. RESULTS: Colorectal cancer screening prevalence in very early, early, late, and non-expansion states all increased during the study period (40.45% vs. 48.14%, 47.52% vs 61.06%, 46.06% vs 58.92%, and 43.44% vs 56.70%). Difference-in-differences analysis showed significantly increased CRC screening prevalence in very early expansion states during 2016 compared to non-expansion states (Crude difference-in-differences + 16.45%, p = 0.02, Adjusted difference-in-differences + 15.9%, p = 0.03). No statistical significance was observed among other years and groups. CONCLUSIONS: Colorectal cancer screening increased between 2012 and 2020 in all states regardless of expansion status. However, Medicaid expansion is not associated with long-term increased colorectal cancer screening prevalence.

Comparison of prostate cancer detection rates in patients undergoing MRI/TRUS fusion prostate biopsy with two different software-based systems.

BACKGROUND: Magnetic resonance imaging (MRI)-targeted prostate biopsy is a routinely used diagnostic tool for prostate cancer (PCa) detection. However, a clear superiority of the optimal approach for software-based MRI processing during biopsy procedures is still unanswered. To investigate the impact of robotic approach and software-based image processing (rigid vs. elastic) during MRI/transrectal ultrasound (TRUS) fusion prostate biopsy (FBx) on overall and clinically significant (cs) PCa detection. METHODS: The study relied on the instructional retrospective biopsy data collected data between September 2013 and August 2017. Overall, 241 men with at least one suspicious lesion (PI-RADS ≥ 3) on multiparametric MRI underwent FBx. The study protocol contains a systematic 12-core sextant biopsy plus 2 cores per targeted lesion. One experienced urologist performed 1048 targeted biopsy cores; 467 (45%) cores were obtained using rigid processing, while the remaining 581 (55%) cores relied on elastic image processing. CsPCa was defined as International Society of Urological Pathology (ISUP) grade ≥ 2. The effect of rigid versus elastic FBx on overall and csPCa detection rates was determined. Propensity score weighting and multivariable regression models were used to account for potential biases inherent to the retrospective study design. RESULTS: In multivariable regression analyses, age, prostate-specific antigen (PSA), and PIRADS ≥ 3 lesion were related to higher odds of finding csPCa. Elastic software-based image processing was independently associated with a higher overall PCa (odds ratio [OR] = 3.6 [2.2-6.1], p < 0.001) and csPCa (OR = 4.8 [2.6-8.8], p < 0.001) detection, respectively. CONCLUSIONS: Contrary to existing literature, our results suggest that the robotic-driven software registration with elastic fusion might have a substantial effect on PCa detection.

Is there a clinical benefit from prostate cancer center certification? An evaluation of functional and oncologic outcomes from 22,649 radical prostatectomy patients.

PURPOSE: To explore whether patients undergoing radical prostatectomy at a German Cancer Society (DKG: Deutsche Krebsgesellschaft) certified center (CC) have superior functional and surgical outcomes compared to patients undergoing radical prostatectomy at a non-certified hospital (nCC). METHODS: A retrospective cohort of 22,649 patients treated between 2008 and 2017 and subsequently recovered at two rehabilitation clinics within 35 days of surgery were analyzed. Urine loss (24 h-pad-test), margin status, and nerve-sparing status at rehab admission were compared between CC and nCC patients, adjusting for age, histopathology (pT, pN, Gleason score), metastases (cM), Karnofsky performance status, time from surgery to rehabilitation, and insurance provider (statutory vs. private). RESULTS: Thirty-four percent of patients underwent surgery at a CC. Complete continence is more pronounced in patients treated in CC (16.6% vs. 24.4%, p < 0.001). In the adjusted models, incontinent patients from CC had less urine loss compared to patients from nCC (- 27.41% difference; 95% CI - 31.71% to - 22.84%, p < 0.001). CC patients were less likely to have positive resection margins (adjusted OR 0.71; 95% CI 0.66 to 0.76, p < 0.001) and more likely to have had a nerve-sparing procedure (adjusted OR 1.29; 95% CI 1.21 to 1.38, p < 0.001). CONCLUSION: Patients treated at certified centers presented to rehab with better urinary continence, higher nerve-sparing rates, and lower positive-margin rates. These results imply superior care at DKG certified centers.

Workplace absenteeism amongst patients undergoing open vs. robotic radical prostatectomy, hysterectomy, and partial colectomy.

BACKGROUND: There is controversy regarding the widespread uptake of robotic surgery across several surgical disciplines. While it has been shown to confer clinical benefits such as decreased blood loss and shorter hospital stays, some argue that the benefits of this technology do not outweigh its high cost. We performed a retrospective insurance-based analysis to investigate how undergoing robotic surgery, compared to open surgery, may impact the time in which an employed individual returns to work after undergoing major surgery. METHODS: We identified a cohort of US adults with employer-sponsored insurance using claims data from the MarketScan database who underwent either open or robotic radical prostatectomy, hysterectomy/myomectomy, and partial colectomy from 2012 to 2016. We performed multiple regression models incorporating propensity scores to assess the effect of robotic vs. open surgery on the number of absent days from work, adjusting for demographic characteristics and baseline absenteeism. RESULTS: In a cohort of 1157 individuals with employer-sponsored insurance, those undergoing open surgery, compared to robotic surgery, had 9.9 more absent workdays for radical prostatectomy (95%CI 5.0 to 14.7, p < 0.001), 25.3 for hysterectomy/myomectomy (95%CI 11.0-39.6, p < 0.001), and 29.8 for partial colectomy (95%CI 14.8-44.8, p < 0.001) CONCLUSION: For the three major procedures studied, robotic surgery was associated with fewer missed days from work compared to open surgery. This information helps payers, patients, and providers better understand some of the indirect benefits of robotic surgery relative to its cost.

Robotic assisted proximal dorsal urethral diverticulectomy.

INTRODUCTION AND HYPOTHESIS: Urethral diverticula are rare but clinically significant entities among female patients. Ventrally located, mid-to distal, simple or horseshoe diverticula are most commonly observed and are usually repaired via a transvaginal approach with varying levels of difficulty but high success rates. Dorsally (anteriorly) located urethral diverticula are more challenging to repair secondary to the need to access the side of the urethra opposite the vaginal lumen, abutting the external urethral sphincter. Unique proximal anatomy in the case presented led to careful consideration of the surgical options. METHODS: We present a review of techniques reported in the literature and a video demonstrating our technique for transabdominal robot-assisted laparoscopic excision of a large, dorsal, very proximally located, crescenteric urethral diverticulum in a patient who initially presented with urosepsis. RESULTS: Robotic-assisted excision of the urethral diverticulum was accomplished in 3:27 h with an estimated blood loss of 50 cc. Vaginal counter-incision was not necessary. The patient's postoperative course was uneventful. Postoperative voiding cystourethrogram prior to suprapubic catheter removal revealed a well-healed repair without extravasation. At 6-month follow-up, she denied any de novo lower urinary tract symptoms such as urinary incontinence, post-void dribbling, urinary tract infection or urinary hesitancy. CONCLUSIONS: Dorsal urethral diverticulum in women, particularly when very proximal, can present a diagnostic and surgical challenge for reconstructive pelvic surgeons. The robotic approach to urethral diverticulectomy is feasible for a proximal dorsal urethral diverticulum which lies cephalad to the pubic symphysis. This or other laparoscopic applications may also be considered as an adjunct to the standard vaginal approach for complex urethral diverticuli with a proximal dorsal component.

Association between Development of Metabolic Acidosis and Improvement of Urinary Continence after Ileal Neobladder Creation.

PURPOSE: Ileal neobladder construction is a common choice for orthotopic urinary diversion following radical cystectomy. We investigated risk factors for metabolic acidosis during the early recovery period. MATERIALS AND METHODS: This study relied on retrospectively collected data on 345 patients who underwent inpatient rehabilitation after radical cystectomy and ileal neobladder construction for bladder cancer between January 2014 and March 2017. Acid-base status, use of sodium bicarbonate to correct metabolic acidosis and continence status were evaluated at the beginning and end of 3 weeks of inpatient rehabilitation. Multivariate logistic regression analysis was performed to identify risk factors associated with the development of metabolic acidosis. RESULTS: At the start of rehabilitation a median of 29 days after surgery (IQR 23-37) 200 patients (58.0%) had metabolic acidosis. During the inpatient rehabilitation period the need for oral sodium bicarbonate replacement due to acidosis increased significantly from 45.2% to 86.7% of patients (p <0.001) while urine loss measured by a 24-hour pad test decreased significantly from a median of 387 (IQR 98-918) to 88 gm (IQR 5-388, p <0.001). The median base excess was within the normal range (-1.2 mmol/l, IQR -2.4 - 0.0) at the end of inpatient rehabilitation. Decreased urinary leakage was identified as an independent risk factor for metabolic acidosis.Conclusions:The risk of metabolic acidosis after neobladder construction correlated with continuously improved continence in the early recovery period. Therefore, during this period the acid-base status should be assessed more frequently to identify metabolic acidosis.

Association of surgical approach and prolonged opioid prescriptions in patients undergoing major pelvic cancer procedures.

BACKGROUND: The rise in deaths attributed to opioid drugs has become a major public health problem in the United States and in the world. Minimally invasive surgery (MIS) is associated with a faster postoperative recovery and our aim was to investigate if the use of MIS was associated with lower odds of prolonged opioid prescriptions after major procedures. METHODS: Retrospective study using the IBM Watson Health Marketscan® Commerical Claims and Encounters Database investigating opioid-naïve cancer patients aged 18-64 who underwent open versus MIS radical prostatectomy (RP), partial colectomy (PC) or hysterectomy (HYS) from 2012 to 2017. Propensity weighted logistic regression analyses were used to estimate the independent effect of surgical approach on prolonged opioid prescriptions, defined as prescriptions within 91-180 days of surgery. RESULTS: Overall, 6838 patients underwent RP (MIS 85.5%), 4480 patients underwent PC (MIS 61.6%) and 1620 patients underwent HYS (MIS 41.8%). Approximately 70-80% of all patients had perioperative opioid prescriptions. In the weighted model, patients undergoing MIS were significantly less likely to have prolonged opioid prescriptions in all three surgery types (Odds Ratio [OR] 0.737, 95% Confidence Interval [CI] 0.595-0.914, p = 0.006; OR 0.728, 95% CI 0.600-0.882, p = 0.001; OR 0.655, 95% CI 0.466-0.920, p = 0.015, respectively). CONCLUSION: The use of the MIS was associated with lower odds of prolonged opioid prescription in all procedures examined. While additional studies such as clinical trials are needed for further confirmation, our findings need to be considered for patient counseling as postoperative differences between approaches do exist.

Wound dehiscence in a sample of 1 776 cystectomies: identification of predictors and implications for outcomes.

OBJECTIVE: To investigate the incidence and predictors of wound dehiscence in patients undergoing radical cystectomy (RC). PATIENTS AND METHODS: In all, 1 776 patient records with Current Procedural Terminology (CPT) codes for radical cystectomy (RC) were extracted from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) between 2005 and 2012. Stratification was made based on the occurrence of postoperative wound dehiscence, defined as loss of integrity of fascial closure. Descriptive and logistic regression models were used to identify predictors of postoperative wound dehiscence. The implications of wound dehiscence on peri- and postoperative outcomes such as complications, mortality, prolonged length of stay (>11 days), and prolonged operative time (>411 min), were assessed. RESULTS: Of 1 776 patients analysed, 57 (3.2%) had a documented wound dehiscence. In multivariable analyses, chronic obstructive pulmonary disease (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.0-4.0; P = 0.03) and high body mass index (OR 2.3, 95% CI 1.3-4.4; P = 0.008) were significant predictors of wound dehiscence. While female gender had significantly lower proportions of wound dehiscence, multivariable analyses did not confirm this (OR 0.4, 95% CI 0.4-1.4; P = 0.75). CONCLUSIONS: Our study is the first to identify predictors of wound dehiscence after RC in a large, contemporary multi-institutional cohort. Identifying patients at risk of postoperative wound complications may guide the use of preventative measures at the time of surgery.

Predicting pathological outcomes in patients undergoing robot-assisted radical prostatectomy for high-risk prostate cancer: a preoperative nomogram.

OBJECTIVE: To identify which high-risk patients with prostate cancer may harbour favourable pathological outcomes at radical prostatectomy (RP). PATIENTS AND METHODS: We evaluated 810 patients with high-risk prostate cancer, defined as having one or more of the following: PSA level of >20 ng/mL, Gleason score ≥8, clinical stage ≥T2c. Patients underwent robot-assisted RP (RARP) with pelvic lymph node dissection, between 2003 and 2012, in one centre. Only 1.6% (13/810) of patients received any adjuvant treatment. Favourable pathological outcome was defined as specimen-confined disease (SCD; pT2-T3a, node negative, and negative surgical margins) at RARP-specimen. Logistic regression models were used to test the relationship among all available predicators and harbouring SCD. A logistic regression coefficient-based nomogram was constructed and internally validated using 200 bootstrap resamples. Kaplan-Meier method estimated biochemical recurrence (BCR)-free and cancer-specific mortality (CSM)-free survival rates, after stratification according to pathological disease status. RESULTS: Overall, 55.2% patients harboured SCD at RARP. At multivariable analysis, PSA level, clinical stage, primary/secondary Gleason scores, and maximum percentage tumour quartiles were all independent predictors of SCD (all P < 0.04). A nomogram based on these variables showed 76% discrimination accuracy in predicting SCD, and very favourable calibration characteristics. Patients with SCD had significantly higher 8-year BCR- (72.7% vs 31.7%, P < 0.001) and CSM-free survival rates (100% vs 86.9%, P < 0.001) than patients with non-SCD. CONCLUSIONS: We developed a novel nomogram predicting SCD at RARP. Patients with SCD achieved favourable long-term BCR- and CSM-free survival rates after RARP. The nomogram may be used to support clinical decision-making, and aid in selection of patients with high-risk prostate cancer most likely to benefit from RARP.

Preventable mortality after common urological surgery: failing to rescue?

OBJECTIVE: To assess in-hospital mortality in patients undergoing many commonly performed urological surgeries in light of decreasing nationwide perioperative mortality over the past decade. This phenomenon has been attributed in part to a decline in 'failure to rescue' (FTR) rates, e.g. death after a complication that was potentially recognisable/preventable. PATIENTS AND METHODS: Discharges of all patients undergoing urological surgery between 1998 and 2010 were extracted from the Nationwide Inpatient Sample and assessed for overall and FTR mortality. Admission trends were assessed with linear regression. Logistic regression models fitted with generalised estimating equations were used to estimate the impact of primary predictors on over-all and FTR mortality and changes in mortality rates. RESULTS: Between 1998 and 2010, an estimated 7,725,736 urological surgeries requiring hospitalisation were performed in the USA; admissions for urological surgery decreased 0.63% per year (P = 0.008). Odds of overall mortality decreased slightly (odds ratio [OR] 0.990, 95% confidence interval [CI] 0.988-0.993), yet the odds of mortality attributable to FTR increased 5% every year (OR 1.050, 95% CI 1.038-1.062). Patient age, race, Charlson Comorbidity Index, public insurance status, as well as urban hospital location were independent predictors of FTR mortality (P < 0.001). CONCLUSION: A shift from inpatient to outpatient surgery for commonly performed urological procedures has coincided with increasing rates of FTR mortality. Older, sicker, minority group patients and those with public insurance were more likely to die after a potentially recognisable/preventable complication. These strata of high-risk individuals represent ideal targets for process improvement initiatives.

Recovery from minimally invasive vs. open surgery in kidney cancer patients: Opioid use and workplace absenteeism.

PURPOSE: Does surgical approach (minimally invasive vs. open) and type (radical vs. partial nephrectomy) affects opioid use and workplace absenteeism. MATERIALS AND METHODS: Retrospective multivariable regression analysis of 2,646 opioid-naïve patients between 18 and 64 undergoing radical or partial nephrectomy via either a minimally invasive vs. open approach for kidney cancer in the United States between 2012 and 2017 drawn from the IBM Watson Health Database was performed. Outcomes included: (1) opioid use in opioid-naïve patients as measured by opioid prescriptions in the post-operative setting at early, intermediate and prolonged time periods and (2) workplace absenteeism after surgery. RESULTS: Patients undergoing minimally invasive surgery had a lower odds of opioid use in the early and intermediate post-operative periods (early: odds ratio [OR], 0.77; 95% confidence interval [CI], 0.62-0.97; p=0.02, intermediate: OR, 0.60; 95% CI, 0.48-0.75; p<0.01), but not in the prolonged setting (prolonged: OR, 1.00; 95% CI, 0.75-1.34; p=0.98) and had earlier return to work (minimally invasive vs. open: -10.53 days; 95% CI, -17.79 to -3.26; p<0.01). Controlling for approach, patient undergoing partial nephrectomy had lower rates of opioid use across all time periods examined and returned to work earlier than patients undergoing radical nephrectomy (partial vs. radical: -14.41 days; 95% CI, -21.22 to -7.60; p<0.01). CONCLUSIONS: Patients undergoing various forms of surgery for kidney cancer had lower rates of peri-operative opioid use, fewer days of workplace absenteeism, but no difference in long-term rates of opioid use in patients undergoing minimally invasive as compared to open surgery.

What is the hospital volume threshold to optimize inpatient complication rate after partial nephrectomy?

OBJECTIVE: To find a cutoff of hospital volume for elective partial nephrectomy (PN) for kidney cancer that can minimize the inpatient morbidity of this procedure. MATERIAL AND METHODS: Analyzing the National Inpatient sample, from 2008 to 2011, we selected 8,753 records of adult patients undergoing elective PN for nonmetastatic kidney cancer, representing an estimated 43,178 partial nephrectomies performed in the United States during this period. Of these, 2,187 (estimated 10,848) PNs were performed via the robotic approach. International Classification of Diseases, Ninth Revision, diagnosis and procedure codes were used to define complications. Logistic regression within generalized estimating equation framework, with restricted cubic splines was used to identify the relationship of any inpatient complications and major inpatient complications with annual hospital PN volume, after adjusting for demographic characteristics, insurance status, location, and comorbidities. A similar analysis was done for a subset of patients undergoing robot-assisted PN. RESULTS: Overall, rate of any inpatient complication and major inpatient complications was 1,801/8,753 (20.6%) and 839/8,753 (9.6%), respectively. Median annual hospital volume was 27 cases (interquartile range: 11-64). Restricted cubic spline analysis revealed a significant inverse nonlinear association between annual hospital volume and any inpatient complications (P<0.001). The odds of complications decreased with increasing annual hospital volume, with plateauing seen at 35 to 40 cases for both any inpatient complications and major inpatient complications. Analysis on a subset of robot-assisted PN revealed a similar inverse nonlinear relationship, with plateauing at 18 to 20 cases annually. CONCLUSION: There is an inverse nonlinear relationship of hospital volume with morbidity of PN, with a plateauing seen at 35 to 40 cases annually overall, and at 18 to 20 cases for robot-assisted PN.

Investigating the effect of treatment at high-volume hospitals on overall survival following cytoreductive nephrectomy.

PURPOSE: Data revealed the benefit of high-volume care in many complex disease processes. Among patients undergoing nephrectomy, those receiving cytoreductive nephrectomy (CN) for metastatic renal cell cancer (mRCC) constitute a unique subset. They often have a greater medical and surgical complexity. Against this backdrop, we sought to investigate the effect of hospital volume on overall survival among patients undergoing CN for mRCC. MATERIAL AND METHODS: We identified 11,089 patients who received CN for mRCC in the National Cancer Database from 1998 to 2012. We ranked hospitals based on annual CN volume. Patients who received surgery in hospitals in the top vs. bottom deciles were compared. Inverse Probability of Treatment Weighting (IPTW)-adjusted Kaplan-Meier and Cox regression analyses were used to compare the primary endpoint of overall survival between balanced cohorts of patients. Secondary endpoints were 30-day mortality, 30-day readmissions, and receipt of subsequent systemic therapy. RESULTS: Median follow-up was 60.39 months (interquartile range [IQR] 35.09-95.95). Median overall survival was 17.61 months (IQR 7.16-44.58). Following propensity score weighting, surgery at a high-volume hospital was associated with a decreased risk of mortality (IPTW-adjusted Cox proportional Hazard Ratio = 0.91; 95% confidence interval: 0.86-0.96). On our IPTW-adjusted Kaplan-Meier analysis, the median survival was 19.94 months (IQR 7.98-50.27) at high-volume hospitals vs. 15.97 months (IQR 6.6-41.56) at low-volume hospitals. With regard to secondary endpoints, the data did not reveal a significant advantage for treatment at a high-volume hospital. CONCLUSION: We found a significant association between receipt of CN at high-volume hospitals and prolonged overall survival, demonstrated by a nearly 4 month survival benefit.

The effect of treatment at minority-serving hospitals on outcomes for bladder cancer.

OBJECTIVES: Healthcare for racial minorities is densely concentrated at a small subset of hospitals in the United States. Understanding long-term outcomes at these minority-serving hospitals is highly relevant to elucidating the sources of racial disparities in cancer care. We investigated the effect of treatment at a minority-serving hospital on overall survival and receipt of definitive treatment for bladder cancer. MATERIALS AND METHODS: Using the National Cancer Database, we identified all patients diagnosed with clinically localized, muscle-invasive bladder cancer between 2004 and 2012. We defined "minority-serving hospitals" as institutions in the top decile by proportion of Black and Hispanic patients within this cohort. Univariate and multivariable analyses were performed to assess the sociodemographic, clinical, and hospital-level factors influencing overall survival and receipt of definitive treatment for bladder cancer. RESULTS: In adjusted analyses, there was no significant difference in overall survival between patients treated at minority-serving hospitals versus those treated at nonminority-serving hospitals (hazard ratio = 0.95, 95% CI: 0.90-1.01). There was also no significance in receipt of definitive treatment between the two hospital types (odds ratio [OR] = 0.85, 95% CI: 0.68-1.06). Black race was independently associated with increased likelihood of mortality (hazard ratio = 1.08, 95% CI: 1.03-1.14) and decreased odds of receiving appropriate definitive treatment (OR = 0.73, 95% CI: 0.66-0.82). CONCLUSIONS: There was no difference between minority-serving and nonminority-serving hospitals in overall survival or receipt of definitive treatment. Black patients suffered worse survival and were less likely to receive definitive treatment for bladder cancer regardless of the type of hospital in which they were treated.

Robot-Assisted Laparoscopic Repair of Extraperitoneal Ureteral Inguinal Hernia with Mesh Placement.

Background: Ureter involvement within indirect hernias is a rare phenomenon usually identified incidentally during herniorrhaphy. Even more rare are extraperitoneal ureteral inguinal hernias, which represent about 20% of these cases and are characterized by a substantial amount of extraperitoneal fat in the hernia defect, the absence of a peritoneal sac, and associated with hydroureteronephrosis and nephroptosis. To date, repair of ureteral inguinal hernias has been performed exclusively using open surgical techniques. We report the first case of successful robot-assisted laparoscopic repair of this rare presentation. Case Presentation: A morbidly obese 70-year-old male with an unremarkable surgical and urological history presents with a 15-year history of nonpainful, enlarging right scrotal swelling measuring 25 cm in diameter. CT imaging revealed right nephroptosis and a hernia defect containing a dilated right ureter looping into the scrotum surrounded by significant extraperitoneal fat. Retrograde pyelography and ureteral catheter placement confirmed a >100 cm ureter. The patient underwent a robot-assisted laparoscopic repair. The inferior epigastric artery, spermatic cord vessels, vas deferens, and ureter were identified. The defect was reduced using external scrotal pressure and reinforced with ProGrip™ self-fixating laparoscopic mesh. The patient was discharged 2 days later following an uneventful postoperative course. Conclusion: Although rare and usually incidentally discovered, extraperitoneal ureteral inguinal hernias can be identified preoperatively by the astute clinician. Preoperative identification allows for improved surgical planning, including a minimally invasive approach. Robot-assisted laparoscopic repair with mesh placement is a feasible alternative to traditional open techniques.

Robotic Buccal Mucosal Graft Ureteroplasty for Complex Ureteral Stricture.

OBJECTIVE: To demonstrate robot-assisted ureterolysis and buccal mucosal graft (BMG) ureteroplasty for the management of a complex, long recurrent ureteral stricture developing after ureterolysis, and also to demonstrate the use of near-infrared fluorescence (NIRF) imaging and intraoperative ureteroscopy during this procedure. METHODS: A 58-year-old man with a history of cabergoline treatment and a cardiac catheterization through the left groin presented with left flank pain and hydronephrosis. A computed tomography scan showed extensive fibrosis around the ureter and a ureteral stricture close to a tortuous left external iliac artery. A computed tomography-guided biopsy showed a benign fibrous tissue around the stricture with no increase in IgG4-expressing plasma cells. A robot-assisted ureterolysis with an omental wrap was performed. One year after the ureterolysis, the patient developed a recurrent ureteral stricture. Retrograde ureterogram showed a long, 6-cm stricture in the upper ureter. For the robotic ureteroplasty, the patient was placed in modified lateral position with port placement similar to the left pyeloplasty. Intraoperative flexible ureteroscopy and NIRF were used to define the distal extent of the stricture. For this, the ureteroscope was advanced until the stricture, and transilluminance of light from the ureteroscope was seen from the robotic camera using Firefly. Ureteral stricture was incised along its length over the ureteroscope. Two BMGs were harvested and sown together to obtain a longer graft. The graft was minimally defatted and brought in the abdomen through one of the ports. The composite graft was then sutured with 4-0 PDS as an onlay graft with the mucosal side facing toward the lumen of the ureter. Ureteroscopy was used to confirm patency, followed by stent placement. NIRF was used to confirm the viability of the ureter and the surrounding tissue. The omental flap was then harvested using a vessel sealer, fixed to the psoas fascia beneath the ureter, and then wrapped over the reconstructed ureter. The omental flap was also tacked to the side of the BMG with a suture to promote blood supply. RESULTS: The procedure was uncomplicated with an operative time of 280 minutes, an estimated blood loss of 75 mL, and an uneventful hospital stay. MAG3 Renal scan after 3 and 6 months of surgery showed no recurrence or obstruction. CONCLUSION: Despite the limitation of being a single case with only a 6-month follow-up, our report shows that robot-assisted BMG is a safe option for the reconstruction of long upper ureteral strictures. This procedure may be a less morbid alternative to an autotransplant and ileal ureter in these patients. However, outcomes need to be studied in a larger series with a longer follow-up.

Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction.

The management options for ureteral obstruction are diverse, including retrograde ureteral stent insertion or antegrade nephrostomy placement, with or without eventual antegrade stent insertion. There is currently no consensus on the ideal treatment or treatment pathway for ureteral obstruction owing, in part, to the varied etiologies of obstruction and diversity of institutional practices. Additionally, different clinicians such as internists, urologists, oncologists and radiologists are often involved in the care of patients with ureteral obstruction and may have differing opinions concerning the best management strategy. The purpose of this manuscript was to review available literature that compares percutaneous nephrostomy placement vs ureteral stenting in the management of ureteral obstruction from both benign and malignant etiologies.

A Clinician's Guide to Avoiding and Managing Common Complications During and After Robot-assisted Laparoscopic Radical Prostatectomy.

CONTEXT: Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications. OBJECTIVE: To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review. EVIDENCE ACQUISITION: In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references. EVIDENCE SYNTHESIS: Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1-42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports. CONCLUSIONS: Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques. PATIENT SUMMARY: Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.