Perioperative, renal function and oncological outcomes of robot-assisted radical nephroureterectomy for patients with upper tract urothelial carcinoma.

PURPOSE: To report perioperative, renal function and oncological outcomes of robot-assisted radical nephroureterectomy (RNU) for patients with upper tract urothelial carcinoma (UTUC). METHODS: This was a retrospective single-arm monocentric study including all consecutive UTUC patients treated with robot-assisted RNU at our institution between 2014 and 2022. Descriptive statistics with median and interquartile range (IQR) for continuous variables and numbers with frequencies for categorical variables were used to report perioperative and renal function outcomes while Kaplan-Meier curves were computed to present extravesical and intravesical recurrence-free survival(RFS) as well as cancer-specific (CSS) and overall survival (OS) with the corresponding 95% confidence intervals(CIs). RESULTS: Overall, 70 patients with a median age of 69.6 [63.3-74.9] years were included in our study. With regards to perioperative outcomes, the median operative time was 157 [130-182] min with a median blood loss of 200 [100-300] cc. Intraoperative complications occurred in 4 (5.7%) patients but no conversion to open or laparoscopic surgery was required. Postoperative complications occurred in 9 (12.9%) patients, including 5 (7.1%) with grade ≥ 3 complications according to the Clavien-Dindo classification. The median length of stay was 4 [3-6] days. With regards to renal function outcomes, the median postoperative loss in estimated glomerular filtration rate at discharge was 16 [10.25-26] mL/min/1.73 m2. With regards to oncological outcomes, the 3-year extravesical and intravesical RFS, CSS and OS rates were 73.6 [62.8-86.2]%, 68.1 [54.6-85]%, 82.5 [72-94.4]% and 75.3 [63.4-89.5]%, respectively. CONCLUSION: We report favorable perioperative and oncological outcomes with expected decrease in renal function after robot-assisted RNU for patients with UTUC.

Impact of Renal Cell Carcinoma Histological Variants on Recurrence After Partial Nephrectomy: A Multi-Institutional, Prospective Study (UROCCR Study 82).

BACKGROUND: The prognostic impact of renal cell carcinoma (RCC) morphotype remains unclear in patients who undergo partial nephrectomy (PN). Our objective was to determine the risk factors for recurrence after PN, including RCC morphotype. METHODS: Patients with RCC who had undergone PN were extracted from the prospective, national French database, UroCCR. Patients with genetic predisposition, bilateral or multiple tumours, and those who had undergone secondary totalization were excluded. Primary endpoint was 5-year, recurrence-free survival (RFS), and secondary endpoint was overall survival (OS). Risk factors for recurrence were assessed by multivariable Cox regression analysis. RESULTS: Overall, 2,767 patients were included (70% male; median age: 61 years [interquartile range (IQR) 51-69]). Most (71.5%) of the PN procedures were robot-assisted. Overall, 2,573 (93.0%) patients were recurrence free, and 74 died (2.7%). Five-year RFS was 84.9% (IQR 82.4-87.4). A significant difference in RFS was observed between RCC morphotypes (p < 0.001). Surgical margins (hazard ratio [HR] = 2.0 [95% confidence interval (CI): 1.3-3.2], p < 0.01), pT stage >1 (HR = 2.6 [95% CI: 1.8-3.7], p < 0.01]) and Fuhrmann grade >2 (HR = 1.9 [95% CI: 1.4-2.6], p < 0.001) were risk factors for recurrence, whereas chromophobe subtype was a protective factor (HR = 0.08 [95% CI: 0.01-0.6], p = 0.02). Five-year OS was 94.0% [92.4-95.7], and there were no significant differences between RCC subgroups (p = 0.06). The main study limitation was its design (multicentre national database), which may be responsible for declarative bias. CONCLUSIONS: Chromophobe morphotype was significantly associated with better RFS in RCC patients who underwent PN. Conversely, pT stage, Fuhrman group and positive surgical margins were risk factors for recurrence.

Continent cutaneous urinary diversion with an ileal pouch with the Mitrofanoff principle versus a Miami pouch in patients undergoing cystectomy for bladder cancer: results of a comparative study.

PURPOSE: Radical cystectomy (RC) is currently the standard of care for non-metastatic muscle invasive bladder cancer. Few studies compare methods of cutaneous continent urinary diversion (CCUD) following RC. The objective was to compare perioperative morbidity and functional outcomes of CCUD using an ileal pouch with a Mitrofanoff efferent versus a Miami ileocolic pouch in patients undergoing cystectomy of pelvic exenteration for bladder cancer. METHODS: This retrospective two-centre study included all consecutive patients who underwent radical cystectomy or pelvic exenteration with CCUD for bladder cancer between 2001 and 2020 in two academic French hospitals with a median follow-up time of 5.4 years. Patients were divided into two groups according to the type of urinary diversion: Miami ileocolonic pouch (group A) and ileal pouch with Mitrofanoff/Monti principle (group B). Continence rate, ability to perform intermittent self-catheterisation, complications and health-related quality of life (HRQoL) measured by the bladder cancer index were evaluated. RESULTS: Thirty-one patients were included. Continence was achieved in 11 out of 14 patients (79%) in group A versus 12 out of 17 patients (71%) in group B (P = 0.3). A significantly higher rate of cutaneous tube stenosis was reported in group B compared to group A (eight (47%) vs. one (7%) patient, respectively; P = 0.02). HRQoL outcomes were similar in both groups except less digestive discomfort observed in group A. CONCLUSIONS: When comparing the ileal pouch with Mitrofanoff/Monti's principle with a Miami pouch, no significant differences were found regarding continence rate, ability to self-catheterise, long-term complication rate and overall patient satisfaction.

Robotic versus open simple prostatectomy for benign prostatic hyperplasia in large glands: single-centre study.

PURPOSE: Robot-assisted simple prostatectomy (RASP) for benign prostatic hyperplasia (BPH) is a recently described surgical approach, but comparison with open simple prostatectomy (OSP) lack in the literature. We compared perioperative outcomes of OSP versus RASP. METHODS: Patients who underwent simple prostatectomy between 2017 and 2020 were included in this retrospective study. OSP was performed by the transvesical technique and RASP was performed with a DaVinci Xi robot, using the transvesical extraperitoneal approach. Perioperative and postoperative data were compared and complications risk factors for complications were identified. RESULTS: and limitations. Overall, 103 patients were included (median age 72 years [IQR = 67-76]). Forty-seven underwent RASP and 56 OSP. The median volume of the prostate gland was 130 mL [IQR = 100-180] in the RASP group and 126 mL [IQR = 100-160] in the OSP group. RASP was associated with a significant reduction in blood loss (median 200 vs. 400 mL; p < 0.001), shorter hospital stay (5 vs. 10 days; p < 0.001) and median catheterisation time (4 vs. 9 days; p < 0.001). In the RASP group, there were fewer grade ≥ 2 complications (2 (4.3%) vs. 13 (23.2%); p = 0.005) and less need for transfusions (0 vs. 6 (11%), p = 0.005). Preoperative prostate volume was a risk factor for complications (OR = 1.2 [95% CI 1.1-1.5]; p = 0.01) while robot-assisted surgery was a protective factor (OR 0.3 [95% CI 0.05-0.9]; p = 0.05). Functional outcomes between the two groups were identical at 12 months follow up. CONCLUSION: RASP is a safe and effective procedure. When compared with OSP, RASP was associated with decreased morbidity as well as reduced hospital stay and catheterisation time. Functional outcomes were comparable to the open approach.

Robotic versus open cystectomy with ileal conduit for the management of neurogenic bladder: a comparative study.

PURPOSE: Cystectomy associated with non-continent ileal diversion is a common surgery in patients with neurogenic bladder. Few data are available, especially for the robotic approach. Our purpose was to compare open cystectomy (OC) and robot-assisted radical cystectomy (RARC) with ileal conduit, regarding peri- and post-operative outcomes. METHODS: We included each patient who underwent cystectomy and ileal conduit for neurogenic bladder in a referral-center between January 2017 and November 2021. Data were retrospectively analyzed. Median follow-up was 16.6 months [IQR: 5; 41]. All patients had neurogenic bladder with failure of conservative treatment and/or impacted Quality of Life (QoL). Open cystectomy with non-continent ileal diversion and robot-assisted cystectomy with intra-corporeal non-continent ileal diversion were compared. Primary endpoint was postoperative complications. Secondary endpoints were length of hospital stay (LOS), surgery duration, blood loss and ureteral anastomosis stricture. RESULTS: A total of 123 patients were included, n = 85 (69.1%) undergoing OC and n = 38 (30.9%) RARC. Significant differences were observed for: operative time (OC 266.9 ± 64 vs. RARC 205.8 ± 55.5 min, p < 0.001), blood loss (OC 737.7 ± 515.8 vs. RARC 245.8 ± 169.6 ml, p < 0.001), delay until feeding resumption (OC 7.1 ± 4.7 vs. RARC 5.5 ± 2.9 days, p = 0.05) and mean LOS (OC 21.6 ± 13.9 vs. RARC 16.2 ± 7.6 days, p = 0.03). In RARC group, there were 10.5% complications Clavien-Dindo > 2 whereas 23.8% complications underwent in the OC group (p = 0.1). CONCLUSION: RARC is a safe approach for management of neurological bladder showing significantly better perioperative outcomes.

Urodynamic assessment and quality of life outcomes of robot-assisted totally intracorporeal radical cystectomy and orthotopic neobladder for bladder cancer: a preliminary study.

PURPOSE: Few data exist regarding the functional outcomes of robot-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder. The aim of this study was to evaluate the urodynamic and functional outcomes in patients undergoing RARC and totally intracorporeal orthotopic neobladder for bladder cancer. METHODS: In this monocentric, observational study carried out between 2016 and 2020, consecutive patients undergoing RARC and intracorporeal orthotopic neobladder in the Department of Urology, Pitié-Salpêtrière Hospital, were included. Reconstruction was totally intracorporeal Y-shaped neobladder. Main outcomes were urodynamic findings 6 months post-surgery, continence and quality of life (QoL). Continence was defined by no pad or one safety pad. International Consultation on Incontinence Questionnaire (ICIQ), International Index of Erectile Function questionnaire (IIEF-5) and Bladder Cancer Index (BCI) scores were recorded. RESULTS: Fourteen male patients were included (median age: 64 years [IQR 54-67]. Median maximal neobladder cystometric capacity was 495 ml [IQR 410-606] and median compliance was 35.5 ml/cm H2O [IQR 28-62]. All patients had post-void residual volume < 30 ml, except for three (22%) who required clean intermittent-self catheterisation. Daytime continence was achieved in 10 patients (71%) and night-time continence in two (14.3%). Median ICIQ score was 7 [IQR 5-11]. Postoperative erectile function was present in 7% of patients (mean IIEF-5 = 5 [IQR 2-7]). Thirteen patients (93%) were satisfied with their choice of neobladder. CONCLUSION: RARC with totally intracorporeal orthotopic neobladder for bladder cancer provides satisfactory urodynamic results and good QoL. These findings should be confirmed long-term.

Preliminary assessment of patient and physician satisfaction with the use of teleconsultation in urology during the COVID-19 pandemic.

PURPOSE: Lockdown during the COVID-19 pandemic compelled urologists to change access to healthcare, especially for oncology patients. Teleconsultation is a safe way to receive medical advice without a risk of infection, and was implemented urgently in our academic centres. Our purpose was to evaluate patient and physician satisfaction with teleconsultation set up during the COVID-19 pandemic. METHODS: From March 16th 2020, all face-to-face consultations were cancelled in France, except for emergencies. Teleconsultation was started immediately by five senior urologists in two academic hospitals. All patients received an email survey including the validated Teleconsultation Satisfaction Questionnaire (TSQ) and demographic questions. Data were collected prospectively. Physicians also responded to the TSQ. Patient satisfaction was measured objectively with the validated 14-item TSQ. Each item was scored on a 5-point Likert scale. Factors associated with positive satisfaction with teleconsultation were assessed by multivariable logistic regression. RESULTS: Overall, 105 patients replied to the survey (91.3%). Median age was 66 years (IQR: 55‒71) and 95 were men (90.5%). Median overall TSQ score was 67 (IQR: 60‒69); teleconsultation was judged to be a good experience by 88 patients (83.8%) and four physicians (80%). Patients who met their surgeon for the first time were more likely to have a good experience (OR = 1.2 [95% CI 1.1‒1.5], p = 0.03). CONCLUSION: Introduced rapidly during the COVID-19 lockdown, urology teleconsultation attained a high level of satisfaction among both patients and physicians. A major change in telemedicine use is foreseen in the post COVID-19 era.

Retrieved but not transplanted kidneys: how to limit the losses? A retrospective national study.

Despite the organ shortage, a significant number of deceased donor kidneys are retrieved but not transplanted (RNTK). This study aims to describe and analyze the main causes of potential grafts discard and to propose adequate solutions. We collected data from the Cristal database of the French Biomedicine Agency about RNTK over one year. Expert opinion was taken from urologists with extensive expertise in renal transplantation. They retrospectively analyzed each record to assess the appropriateness of each graft refusal and subsequent kidney discard. Of 252 kidneys were retrieved but not transplanted in France over one year. The main reasons for discard were vascular abnormalities in 43.7% (n = 110), suspicion of malignant tumor in 18.7% (n = 47), and severe histological lesions on preimplantation biopsy in 12.3% (n = 31). The reason for kidney refusal was undetermined in 4.8% (n = 12). Iatrogenic lesions were responsible for 26.2% (n = 66). Overall, 46.0% (n = 16) and 25.0% (n = 63) of the grafts were, respectively, properly and improperly denied, and the analysis was not possible in 29.0% (n = 73). In total, 36.9% of RNTK could have been transplanted. Reduction of iatrogenic lesions, improvement of microsurgical repair skills, and proper histological examination are necessary to reduce the number of RNTK. A prospective study applying the proposed principles is undoubtedly essential to complete this work.

Multi-Institutional Assessment of Routine Same Day Discharge Surgery for Robot-Assisted Radical Prostatectomy.

PURPOSE: We assessed the multi-institutional safety of same day discharge for robot-assisted radical prostatectomy within a single health care system. MATERIALS AND METHODS: We included 358 patients undergoing planned same day discharge for robot-assisted radical prostatectomy at 6 French centers. Primary outcomes were same day discharge failure, and 30-day complication and readmission rates. Secondary outcomes included preoperative characteristics, perioperative parameters, Chung score and pain visual analogue scale at discharge, pathological features and followup. RESULTS: Mean patient age was 64.7 years. Mean operative time and blood loss were 147.5 minutes and 228 ml, respectively. Concomitant lymph node dissection and nerve sparing procedures were performed in 43% and 62% of cases, respectively. No patient required transfusion or conversion. The same day discharge failure, complication and readmission rates were 4.2%, 16.8% and 2.8%, respectively. The most frequent complications were low grade complications including urinary infection (6.4%) and ileus (2.8%). Blood loss, lymph node dissection and pain visual analogue scale were significantly correlated with same day discharge failure. Same day discharge failure was reported in 7.8% of patients with pelvic lymph node dissection compared with only 1.5% of patients who did not undergo lymph node dissection (p=0.003). ASA® score was the only factor significantly associated with postoperative complications (p=0.023). The only factor correlated with readmission was the pain visual analogue scale at discharge (p=0.017). CONCLUSIONS: This first multi-institutional evaluation confirms the safety of same day discharge robot-assisted radical prostatectomy in a single health care system and identifies for the first time factors associated with same day discharge failure and readmission. These findings may help physicians anticipate ideal same day discharge candidates and adapt postoperative followup.

Robotic versus open radical cystectomy throughout the learning phase: insights from a real-life multicenter study.

BACKGROUND AND OBJECTIVES: Robot-assisted radical cystectomy (RARC) has been shown to be non-inferior to open radical cystectomy (ORC) for the treatment of bladder cancer (BC). However, most data on RARC come from high-volume surgeons at high-volume centers. The objective of the study was to compare perioperative and mid-term oncologic outcomes of RARC versus ORC in a real-life cohort of patients treated by surgeons starting their experience with RARC. MATERIALS AND METHODS: Data were prospectively collected from consecutive patients undergoing RARC and ORC at five referral Centers between 2010 and 2016 by five surgeons (one per center) with no prior experience in RARC. Patients with high-risk non-muscle-invasive or organ-confined muscle-invasive (T2N0M0) bladder cancer were considered for RARC. The main study endpoints were perioperative outcomes, postoperative surgical complications, and mid-term oncologic outcomes. RESULTS: Overall, 124 and 118 patients underwent RARC and ORC, respectively. Baseline patients' and tumors' characteristics were comparable between the two groups. Yet, the proportion of patients receiving neoadjuvant chemotherapy was significantly higher in the RARC cohort. Median operative time was significantly higher, while median EBL, LOH, and transfusion rates were significantly lower after RARC. Median number of lymph nodes removed was significantly higher after RARC. All other histopathological outcomes, as well as the rate of early (< 30 days) and late postoperative complications, were comparable to ORC. At a median follow-up of 2 years, 29 (23%) and 41 (35%) patients developed disease recurrence (p = 0.05), while 20 (16%) and 37 (31%) died of bladder cancer (p = 0.005) after RARC and ORC, respectively. CONCLUSIONS: With proper patient selection, RARC was non-inferior to ORC throughout the surgeons' learning phase. Yet, the observed differences in oncologic outcomes suggest selection bias toward adoption of RARC for patients with more favorable disease characteristics.

Long-term oncological outcomes after robotic partial nephrectomy for renal cell carcinoma: a prospective multicentre study.

PURPOSE: This study aimed at reporting the long-term oncological outcomes of robotic partial nephrectomy (RPN) for renal cell carcinoma (RCC). METHODS: Data from all consecutive patients who underwent RAPN for RCC from July 2009 to January 2012 in three departments of urology were prospectively collected. Overall survival (OS), cancer-specific survival (CSS) and disease free-survival (DFS) were estimated using the Kaplan-Meier method. Prognostic factors associated with CSS were sought in univariate analysis. The log-rank test was used for categorical variables and the Cox model for continuous variables. RESULTS: 110 patients were included with a median follow-up of 64.4 months [95% CI = (61.0-66.7)]. Median age was 61 years (29-83) with 62.7% of men and 37.3% of women. Median RENAL score was 6 (4-10) with elective indications accounting for 95% of cases. Out of 27 patients (24.5%) who experienced peri-operative complication, 12 patients (10.9%) had a major complication (Clavien-Dindo grade ≥ 3). The TRIFECTA achievement rate was 52.7%. Three patients (2.7%) experienced local recurrence and seven patients (6.4%) progressed to a metastatic disease. 5-year OS, CSS, DFS were 94.9, 96.8, 86.4%, respectively. In univariate analysis, no pre/peri-operative characteristic was associated with DFS. No port-site metastasis was observed and there was one case of peritoneal carcinomatosis. CONCLUSION: In this multicenter series, long-term OS, DFS and CSS after RPN appeared comparable to large series of open partial nephrectomy, with no port-site metastasis and one case of peritoneal carcinomatosis.

Perioperative outcomes and complications of intracorporeal vs extracorporeal urinary diversion after robot-assisted radical cystectomy for bladder cancer: a real-life, multi-institutional french study.

PURPOSE: To compare perioperative outcomes and complications of extracorporeal (ECUD) vs intracorporeal urinary diversion (ICUD) in patients after undergoing robot-assisted radical cystectomy (RARC) at five referral centers in France. METHODS: We retrospectively reviewed our multi-institutional, prospectively-collected database to select patients undergoing RARC between 2010 and 2016 with at least 3 months of follow-up. At each center, the surgery was performed by one surgeon with extensive experience in robotic surgery and radical cystectomy but no prior experience in RARC. RESULTS: Overall, 108 patients were included. ECUD and ICUD were performed in 34 (31.5%) and 74 (68.5%) patients, respectively. Patient characteristics were comparable among the two groups, except for a higher proportion of patients with high surgical risk (ASA score ≥ 3) in the ECUD group. Ileal conduit and ileal neobladder were performed in 63/108 (58%) and 45/108 (42%) cases, respectively. Ileal conduit was performed more often with an extracorporeal approach while ileal neobladder with an intracorporeal approach. Overall, operative time, length of hospital stay, positive margin rate, and number of lymph nodes removed did not significantly differ among the two cohorts. Estimated blood loss and transfusion rates were significantly higher in the ECUD group. Rate of early (38.2 vs 47.3%, p = 0.4) and late (29.4 vs 18.9%, p = 0.2) surgical complications did not significantly differ between the ECUD and ICUD groups. Results were comparable in the subgroup analysis in the ileal conduit subpopulation. CONCLUSION: In our real-life, multi-institutional study, RARC with ICUD achieved perioperative outcomes and complication rates comparable to those of RARC with ECUD.

A systematic review of the treatment for female stress urinary incontinence by ACT® balloon placement (Uromedica, Irvine, CA, USA).

PURPOSE: (1) To describe the minimally invasive adjustable continence therapy (ACT)(®) balloon placement surgical technique. (2) To analyse the results of ACT(®) balloon in the treatment for female stress urinary incontinence (SUI). METHOD: A review of the literature was performed by searching the PubMed database using the following search terms: ACT balloons, female urinary incontinence, and female continence. RESULTS: Eight studies were published between 2007 and 2013. The mean follow-up of these studies was 1-6 years. The mean age of the patients ranged between 62 and 73 years; 40-100 % of patients had already been treated surgically for their SUI. A significant reduction in the number of pads used per day was observed after ACT(®) balloon placement, with improvement of short pad tests from 49.6 to 77.3 g preoperatively to 11.2-25.7 g after ACT(®) balloon placement. Fifteen to 44 % of patients considered that their SUI had been cured and 66-78.4 % were satisfied with the result. The explantation rate ranged between 18.7 and 30.8 %. Quality of life was significantly improved, and no major complication was reported. CONCLUSION: ACT(®) balloons constitute a reasonable, minimally invasive alternative for the treatment for female SUI due to intrinsic sphincter disorder, especially in patients who have already experienced failure of standard surgical treatment and in clinical settings incompatible with invasive surgical placement of an artificial urinary sphincter (especially women over the age of 80 years). Long-term results are essential to evaluate the efficacy of this treatment.

Impact of the length of time between diagnosis and surgical removal of urologic neoplasms on survival.

OBJECTIVE: Our aim was to assess the effect of surgical wait time on the survival of patients with urological neoplasms, including prostate, bladder, penile, and testicular cancers and upper tract tumours (UTUC). MATERIALS AND METHODS: Current, relevant studies were identified from the literature. Keywords used for article retrieval were as follows: delay; surgery; prostate cancer; urothelial carcinoma; renal cell carcinoma; testicular cancer; bladder; renal pelvis; ureter; and survival. RESULTS: Regarding the length of surgical wait time, it does not matter in cases of incidental T1a renal cell carcinomas. In other cases of renal cell carcinomas, surgery should be considered within <1 month; it is of crucial importance in bladder cancer and should be <1 month for a TURBT in cases of non-muscle-invasive bladder cancer and <1 month for a radical cystectomy in cases of muscle-invasive bladder cancer; it is important in invasive UTUC and should be <1 month for a radical nephroureterectomy; it is not crucial in cases of low-risk prostate cancer. In any other case, radical prostatectomy should be considered within <2 months; it is important in testicular cancer and should be fewer than 10 days for an orchiectomy. CONCLUSION: Prolonged surgical wait times have an impact on the overall quality of life and anxiety of the patient. Extending the wait time beyond a given threshold can also have a negative impact on the patient's clinical outcomes, but this threshold differs between urological neoplasms.

Robot-assisted Periprostatic Artificial Urinary Sphincter Implantation in Men with Neurogenic Stress Urinary Incontinence: Description of the Surgical Technique and Comparison of Long-term Functional Outcomes with the Open Approach.

BACKGROUND: Periprostatic artificial urinary sphincter implantation (pAUSi) is a rare yet relevant indication for male neurogenic stress urinary incontinence (SUI). OBJECTIVE: To describe the surgical technique of robot-assisted pAUSi (RApAUSi) and compare the long-term functional results with the open pAUSi (OpAUSi). DESIGN, SETTING, AND PARTICIPANTS: Data of 65 consecutive men with neurogenic SUI undergoing pAUSi between 2000 and 2022 in a tertiary centre were collected retrospectively. SURGICAL PROCEDURE: Thirty-three patients underwent OpAUSi and 32 underwent RApAUSi. OpAUSi cases were performed by a single surgeon, experienced in functional urology and prosthetic surgery. RApAUSi cases were performed by the same surgeon together with a second surgeon, experienced in robotic surgery. MEASUREMENTS: Outcome measures were achievement of complete urinary continence, intra- and postoperative complications, and surgical revision-free survival (SRFS). RESULTS AND LIMITATIONS: RApAUSi showed superior results to OpAUSi in terms of median (interquartile range) operative time (RApAUSi: 170 [150-210] min vs OpAUSi: 245 [228-300] min; p < 0.001), estimated blood loss (RApAUSi: 20 [0-50] ml vs OpAUSi: 500 [350-700] ml; p < 0.001), and median length of hospital stay (LOS; RApAUSi: 5 [4-6] d vs OpAUSi: 11 [10-14] d; p < 0.001). Clavien-Dindo grade ≥3a complications occurred more frequently after OpAUSi (RApAUSi: 1/32 [3%] vs OpAUSi: 10/33 [30%]; p = 0.014). Achievement of complete urinary continence (zero pads) was comparable between the groups (RApAUSi: 24/32 [75%] vs OpAUSi: 24/33 [73%]; p = 0.500). The median follow-up periods were 118 (50-183) and 56 (25-84) mo for OpAUSi and RApAUSi, respectively (p < 0.001). A tendency towards longer SRFS was observed in the RApAUSi group (p = 0.076). The main study limitation was its retrospective nature. CONCLUSIONS: RApAUSi is an efficient alternative to OpAUSi, resulting in shorter operative times, less blood loss, fewer severe complications, and a shorter LOS with similar functional results and need for revision surgery. PATIENT SUMMARY: Compared with open periprostatic artificial urinary sphincter implantation (pAUSi), robot-assisted pAUSi leads to faster recovery and similar functional results, with fewer postoperative complications.

Continent cutaneous diversion: Unveiling the interplay of neuro-urology and oncological challenges.

OBJECTIVES: The objective of our study is to demonstrate the practical application of continent cutaneous urinary diversion (CCUD) in oncological patients, with a focus on various aspects of the procedure: surgical challenges, functional outcomes, and quality of life. MATERIALS AND METHODS: We studied the perioperative and follow-up data of patients who underwent cystectomy for cancer associated with CCUD (Mitrofanoff, Monti or Casale). We retrospectively analyzed complications within 30days and beyond 30days post-surgery. We evaluated oncological outcomes. Patients' quality of life was assessed using the Bladder Cancer Index (BCI) questionnaire. Results are given on an intention-to-treat basis. RESULTS: A total of 24 patients were included in the study (July 2001 and May 2022), with a median follow-up of 62.5months. We report three deaths due to neoplasic recurrence. Forty-six percent had an early postoperative complication, two of whom required revision surgery. Overall, the medium-term complication rate was 70% and the reoperation rate was 62%. There were 8 stomal cutaneous stenoses (33%) and 3 uretero-ileal stenoses (12.5%). Overall satisfaction was rated at 9.2/10 on average, and body image was unaltered or slightly altered in 62.5% of patients. Of the patients who responded to the BCI, 75% had complete continence. DISCUSSION: The experience gained with continent stomas in neuro-urology has allowed, in carefully selected cases, to offer patients an alternative that can improve their quality of life in a context already burdened by the shadow of cancer. CCUD can be proposed as an alternative to Bricker diversion in cases of urethral invasion or a high risk of neobladder incontinence, in selected patients.

Management of patients with muscle-invasive bladder cancer with clinical evidence of pelvic lymph node metastases.

Identification of clinically positive pelvic lymph node metastases (cN+) in patients with muscle-invasive bladder cancer is currently challenging, as the diagnostic accuracy of available imaging modalities is limited. Conventional CT is still considered the gold-standard approach to diagnose lymph node metastases in these patients. The development of innovative diagnostic methods including radiomics, artificial intelligence-based models and molecular biomarkers might offer new perspectives for the diagnosis of cN+ disease. With regard to the treatment of these patients, multimodal strategies are likely to provide the best oncological outcomes, especially using induction chemotherapy followed by radical cystectomy and pelvic lymph node dissection in responders to chemotherapy. Additionally, the use of adjuvant nivolumab has been shown to decrease the risk of recurrence in patients who still harbour ypT2-T4a and/or ypN+ disease after surgery. Alternatively, the use of avelumab maintenance therapy can be offered to patients with unresectable cN+ tumours who have at least stable disease after induction chemotherapy alone. Lastly, patients with cN+ tumours who are not responding to induction chemotherapy are potential candidates for receiving second-line treatment with pembrolizumab.

Robot-assisted laparoscopic artificial urinary sphincter insertion in men with neurogenic stress urinary incontinence.

OBJECTIVE: To describe for the first time the technique of robot-assisted artificial urinary sphincter (R-AUS) insertion in male patients with neurogenic incontinence. MATERIALS AND METHODS: From January 2011 to the present date, six patients with spinal cord injury have undergone R-AUS insertion at our academic institution and we have prospectively collected data on pre-, peri- and early postoperative outcomes. A transperitoneal five-port approach was used using a three-arm standard da Vinci® robot (Intuitive Surgical, Sunnyvale, CA, USA) in a 30° reverse Trendelenburg position. The artificial urinary sphincter (AUS) cuff was placed circumferentially around the bladder neck, the reservoir was left intra-abdominally in a lateral vesicular space and the pump was placed in a classic scrotal position. RESULTS: All six patients had successful robotic implantation of the AUS. The median patient age was 51.5 years, the median (range) operating time was 195 (175-250) min with no significant blood loss or intra-operative complications. The median (range) length of hospital stay was 4 (4-6) days. At a median (interquartile range) follow-up of 13 (6-21) months, all six patients had a functioning device with complete continence. To date, we have observed no incidence of early erosion, device infection or device malfunction. CONCLUSIONS: Allowing for the preliminary nature of our data, R-AUS insertion appears safe and technically feasible. Larger studies with long-term follow-up and comparison with open AUS insertion are necessary before definitive statements can be made for R-AUS in respect of complications and functional outcomes.

Current role of image-guided robotic radiosurgery (Cyberknife(®) ) for prostate cancer treatment.

OBJECTIVES: To describe the most recent data from phase I and II clinical trials of stereotactic body radiation therapy (SBRT) using image-guided robotic radiosurgery, specifically the Cyberknife(®) (Accuracy Incorporated, Sunnyvale, CA, USA). To better determine thecurrent role of this type of radiosurgery in prostate cancer (PCa) management. MATERIALS AND METHODS: Current clinical trials and relevant retrospective studies were identified from the literature, clinical trial databases, websites and conference abstracts. The indications, technical aspects, efficacy and toxicity of SBRT using the Cyberknife(®) system were summarized. RESULTS: The Cyberknife(®) system is an experimental treatment mostly used for localized PCa in stage cT1/T2a-b N0 M0 with a Gleason score ≤ 7 and PSA level ≤ 20 ng/mL. Hypofractionated radiation therapy was delivered in five fractions of 7-7.25 Gy for a total dose of 35-36.25 Gy. After treatment, the median PSA levelfell from 4.9-8.3 ng/mL to 0.1-1.6 ng/mL at a median follow-up of 4-60 months. The biochemical progression-free survival rates ranged from 78.3 to 100%. Acute and late toxicities were mostly grade 1/2 rectal or urinary complications. Few grade 3 and no grade 4 toxicities occurred during follow-up; however, erectile dysfunction and testes toxicity were also reported. CONCLUSIONS: The use of the Cyberknife(®) system is limited mainly by its pretreatment and maintenance costs. Despite encouraging preliminary results, longer-term follow-up and randomized controlled phase III clinical trials are necessary before the Cyberknife(®) system becomes a standard treatment method.