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.

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.

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.

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.

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.

Selective arterial clamping does not improve outcomes in robot-assisted partial nephrectomy: a propensity-score analysis of patients without impaired renal function.

OBJECTIVES: To assess the benefit of selective arterial clamping (SAC) as an alternative to main renal artery clamping (MAC) during robot-assisted partial nephrectomy (RAPN) in patients without underlying chronic kidney disease (CKD). PATIENTS AND METHODS: Our study cohort comprised 665 patients without impaired renal function undergoing MAC (n = 589) or SAC (n = 76) during RAPN from four medical institutions in the period 2008-2015. We compared complication rates, positive surgical margin (PSM) rates, and peri-operative and intermediate-term renal functional outcome between 132 patients undergoing MAC and 66 undergoing SAC after 2-to-1 nearest-neighbour propensity-score matching for age, sex, body mass index, RENAL nephrometry score, tumour size, baseline estimated glomerular filtration rate (eGFR), American Society of Anesthesiologists (ASA) score, Charlson comorbidity index (CCI) and warm ischaemia time (WIT). RESULTS: In propensity-score-matched patients, PSM (5.7 vs 3.0%; P = 0.407) and complication rates (13.8 vs 10.6%; P = 0.727) did not differ between the MAC and SAC groups. The incidence of acute kidney injury for MAC vs SAC (25.0 vs 32.0%; P = 0.315) within the first 30 days was similar. At a median follow-up of 7.5 months, the percentage reduction in eGFR (-9.3 vs -10.4%; P = 0.518) and progression to CKD ≥ stage 3 (7.2 vs 8.5%; P = 0.792) showed no difference. CONCLUSIONS: Our study findings show no difference in PSM rates, complication rates or intermediate-term renal functional outcomes between patients with unimpaired renal function who underwent SAC vs those who underwent MAC. When expected WIT is low, the routine use of SAC may not be necessary. Further studies will need to determine the role of SAC in patients with a solitary kidney or with significantly impaired renal function.

Spontaneous passage of ureteral stones in patients with indwelling ureteral stents.

INTRODUCTION: To determine rates of spontaneous ureteral stone passage in patients with indwelling ureteral stents, and to identify factors associated with the spontaneous passage of stones while a ureteral stent is in place. MATERIALS AND METHODS: From our institutional database, we identified patients who underwent ureteroscopic procedures for stone disease between January 1, 2013 and March 1, 2015. We compared the rates of spontaneous stone passage between patients who had previously undergone ureteral stent placement and those who had not. In patients with indwelling stents, multivariate logistic regression was performed to identify factors associated with spontaneous stone passage. RESULTS: A total of 194 patients met inclusion criteria. Spontaneous stone passage rates were similar in the stented (17/119, 14%) and non-stented (15/75, 20%) groups (p = 0.30). In bivariate analysis of stented patients, smaller stone size (p < 0.001) and distal stone location (p = 0.01) were significantly associated with spontaneous stone passage. Multivariate logistic regression analysis of stented patients showed that only small stone size was significantly associated with the likelihood of stone passage (p = 0.01), whereas stent duration, stone location, and stone laterality were not. CONCLUSIONS: A small, but clinically significant percentage of ureteral stones pass spontaneously with a ureteral stent in place. Small stone size is associated with an increased likelihood of spontaneous passage in patients with indwelling stents. These findings may help to identify patients who can potentially avoid additional surgical procedures for definitive stone removal after ureteral stent placement.

Complications of Minimally Invasive Surgery and Their Management.

Minimally invasive surgery, including both traditional laparoscopic and robot-assisted laparoscopic approaches, has increasingly become the standard of care for urologic abdominal and pelvic surgery. This is a comprehensive review of the contemporary literature regarding complications of laparoscopic and robotic urologic surgery. The review highlights pertinent studies with the goal of providing the minimally invasive urologic surgeon with an up-to-date overview of general and procedure-specific complications and their management.

Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes.

OBJECTIVE: To evaluate the utility of robotic repair of injuries to the ureter or bladder from obstetrical and gynaecological (OBGYN) surgery PATIENTS AND METHODS: A retrospective review of all patients from four different high-volume institutions between 2002 and 2013 that had a robot-assisted (RA) repair by a urologist after an OBGYN genitourinary injury. RESULTS: Of the 43 OBGYN operations, 34 were hysterectomies: 10 open, 10 RA, nine vaginally, and five pure laparoscopic. Nine patients had alternative OBGYN operations: three caesarean sections, three oophorectomies (one open, two laparoscopic), one RA colpopexy, one open pelvic cervical cerclage with mesh and one RA removal of an invasive endometrioma. In all, 49 genitourinary (GU) injuries were sustained: ureteric ligation (26), ureterovaginal fistula (10), ureterocutaneous fistula (one), vesicovaginal fistula (VVF; 10) and cystotomy alone (two). In all, 10 patients (23.3%) underwent immediate urological repair at the time of their OBGYN RA surgery. The mean (range) time between OBGYN injury and definitive delayed repair was 23.5 (1-297) months. Four patients had undergone prior failed repair: two open VVF repairs and two balloon ureteric dilatations with stent placement. In all, 22 ureteric re-implants (11 with ipsilateral psoas hitch) and 15 uretero-ureterostomies were performed. Stents were placed in all ureteric cases for a mean (range) of 32 (1-63) days. In all, 10 VVF repairs and two primary cystotomy closures were performed. Drains were placed in 28 cases (57.1%) for a mean (range) of 4.1 (1-26) days. No case required open conversion. Two patients (4.1%) developed ureteric obstruction after RA repair requiring dilatation and stenting. The mean (range) follow-up of the entire cohort was 16.6 (1-63) months. CONCLUSIONS: RA repair of GU injuries during OBGYN surgery is associated with good outcomes, appears safe and feasible, and can be used successfully immediately after injury recognition or as a salvage procedure after prior attempted repair. RA techniques may improve convalescence in a patient population where quick recovery is paramount.

Augmented-reality-based skills training for robot-assisted urethrovesical anastomosis: a multi-institutional randomised controlled trial.

OBJECTIVE: To validate robot-assisted surgery skills acquisition using an augmented reality (AR)-based module for urethrovesical anastomosis (UVA). METHODS: Participants at three institutions were randomised to a Hands-on Surgical Training (HoST) technology group or a control group. The HoST group was given procedure-based training for UVA within the haptic-enabled AR-based HoST environment. The control group did not receive any training. After completing the task, the control group was offered to cross over to the HoST group (cross-over group). A questionnaire administered after HoST determined the feasibility and acceptability of the technology. Performance of UVA using an inanimate model on the daVinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) was assessed using a UVA evaluation score and a Global Evaluative Assessment of Robotic Skills (GEARS) score. Participants completed the National Aeronautics and Space Administration Task Load Index (NASA TLX) questionnaire for cognitive assessment, as outcome measures. A Wilcoxon rank-sum test was used to compare outcomes among the groups (HoST group vs control group and control group vs cross-over group). RESULTS: A total of 52 individuals participated in the study. UVA evaluation scores showed significant differences in needle driving (3.0 vs 2.3; P = 0.042), needle positioning (3.0 vs 2.4; P = 0.033) and suture placement (3.4 vs 2.6; P = 0.014) in the HoST vs the control group. The HoST group obtained significantly higher scores (14.4 vs 11.9; P 0.012) on the GEARS. The NASA TLX indicated lower temporal demand and effort in the HoST group (5.9 vs 9.3; P = 0.001 and 5.8 vs 11.9; P = 0.035, respectively). In all, 70% of participants found that HoST was similar to the real surgical procedure, and 75% believed that HoST could improve confidence for carrying out the real intervention. CONCLUSION: Training in UVA in an AR environment improves technical skill acquisition with minimal cognitive demand.

Preoperative Predictors of Surgical Success for Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures.

OBJECTIVE: To investigate predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for ureteropelvic junction obstruction (UPJO), proximal, and middle ureteral stricture disease. METHODS: We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery database to identify all consecutive patients undergoing RUR for UPJO, proximal and/or middle ureteral stricture disease between April 2012 and December 2020. The specific reconstruction technique was determined by the primary surgeon based on clinical history and intraoperative findings. Patients were grouped according to whether they were surgical successful. Preoperative variables between both groups were compared using chi-square tests. All independent variables with associations of P <.2 then underwent a binary logistic regression analysis to determine predictive variables of success for RUR (P ≤.05 was considered statistically significant). RESULTS: Overall, 338 patients met inclusion criteria. Surgical success rates of RUR are shown in Table 1. Univariate analysis (Table 2) showed that there were a lower proportion of patients with diabetes (8.9% vs 25.7%, P <.01) and a higher proportion of patients who underwent ureteral rest (74.3% vs 48.6%, P <.01) in the surgical success group. Multivariate logistic regression analysis (Table 3) further revealed the odds of surgical success in patients without diabetes was 3.08 times ((confidence interval) CI 1.26-7.54, P = .01) the odds of success for patients with diabetes. The odds of surgical success in patients who underwent preoperative ureteral rest were 2.8 times (CI 1.35-5.83, P = .01) the odds of success for patients who did not undergo preoperative ureteral rest. CONCLUSION: Surgical success of RUR for management of UPJO, proximal, and middle ureteral strictures may be influenced by factors including preoperative ureteral rest and presence of diabetes.

Anatomical Location of the Vesical Branches of the Inferior Hypogastric Plexus in Human Cadavers.

We have demonstrated in canines that somatic nerve transfer to vesical branches of the inferior hypogastric plexus (IHP) can be used for bladder reinnervation after spinal root injury. Yet, the complex anatomy of the IHP hinders the clinical application of this repair strategy. Here, using human cadavers, we clarify the spatial relationships of the vesical branches of the IHP and nearby pelvic ganglia, with the ureteral orifice of the bladder. Forty-four pelvic regions were examined in 30 human cadavers. Gross post-mortem and intra-operative approaches (open anterior abdominal, manual laparoscopic, and robot-assisted) were used. Nerve branch distances and diameters were measured after thorough visual inspection and gentle dissection, so as to not distort tissue. The IHP had between 1 to 4 vesical branches (2.33 ± 0.72, mean ± SD) with average diameters of 0.51 ± 0.06 mm. Vesical branches from the IHP arose from a grossly visible pelvic ganglion in 93% of cases (confirmed histologically). The pelvic ganglion was typically located 7.11 ± 6.11 mm posterolateral to the ureteral orifice in 69% of specimens. With this in-depth characterization, vesical branches from the IHP can be safely located both posterolateral to the ureteral orifice and emanating from a more proximal ganglionic enlargement during surgical procedures.

Outcomes of Robotic Simple Prostatectomy After Prior Failed Endoscopic Treatment of Benign Prostatic Hyperplasia.

Background: We compared outcomes of robot-assisted simple prostatectomy (RASP) in patients with and without a history of prior prostate surgery for management of symptomatic benign prostatic hyperplasia (BPH). Methods: We retrospectively reviewed our multi-institutional database for all consecutive patients who underwent RASP between May 2013 and January 2021. Postoperatively, urinary function was assessed using the American Urological Association symptom score (AUASS) and quality of life (QOL) score. Results: Overall, 520 patients met inclusion criteria. Among the 87 (16.7%) patients who underwent prior prostate surgery, 49 (56.3%), 26 (29.9%), 8 (9.2%), 3 (3.4%), and 1 (1.1%) patients underwent transurethral resection of the prostate, photoselective vaporization of the prostate, transurethral microwave therapy, prostatic urethral lift, or water vapor thermal therapy, respectively. There was no difference in mean prostate volume (p = 0.40), estimated blood loss (p = 0.32), robotic console time (p = 0.86), or major 30-day postoperative (Clavien >2) complications (p = 0.80) between both groups. With regard to urinary function, the mean improvement in preoperative and postoperative AUASS (p = 0.31), QOL scores (p = 0.11), and continence rates was similar between both groups. Conclusion: For management of patients with BPH and lower urinary tract symptoms, RASP is associated with an improvement in urinary function outcomes and a low risk of postoperative complications. Perioperative outcomes of RASP are similar in patients who underwent prior prostate surgery vs those that did not undergo prior prostate surgery.

A sheep in wolf's clothing; a case of renal leiomyoma masquerading as hereditary leiomyomatosis and renal cell carcinoma.

Active surveillance has become a standard of care for the management of small renal masses. Decision to transition from surveillance to intervention relies on several factors including growth kinetics, histologic grade on biopsy and patient comorbidities. Management of renal masses in pregnancy presents a unique change when clinical triggers must be weighed with risk to fetus. We present the case of a third trimester patient with an enlarging and enhancing renal mass managed with robotic assisted laparoscopic partial nephrectomy. Histologic analysis was consistent with renal leiomyoma. Renal leiomyomas are a rare benign mesenchymal tumor influenced by changes in progesterone-estrogen axis.