Robotic ureteral reconstruction for recurrent strictures after prior failed management.

Objectives: To describe our multi-institutional experience with robotic ureteral reconstruction (RUR) in patients who failed prior endoscopic and/or surgical management. Materials and Methods: We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients who underwent RUR between 05/2012 and 01/2020 for a recurrent ureteral stricture after having undergone prior failed endoscopic and/or surgical repair. Post-operatively, patients were assessed for surgical success, defined as the absence of flank pain and obstruction on imaging. Results: Overall, 105 patients met inclusion criteria. Median stricture length was 2 (IQR 1-3) centimetres. Strictures were located at the ureteropelvic junction (UPJ) (41.0%), proximal (14.3%), middle (9.5%) or distal (35.2%) ureter. There were nine (8.6%) radiation-induced strictures. Prior failed management included endoscopic intervention (49.5%), surgical repair (25.7%) or both (24.8%). For repair of UPJ and proximal strictures, ureteroureterostomy (3.4%), ureterocalicostomy (5.2%), pyeloplasty (53.5%) or buccal mucosa graft ureteroplasty (37.9%) was utilized; for repair of middle strictures, ureteroureterostomy (20.0%) or buccal mucosa graft ureteroplasty (80.0%) was utilized; for repair of distal strictures, ureteroureterostomy (8.1%), side-to-side reimplant (18.9%), end-to-end reimplant (70.3%) or appendiceal bypass (2.7%) was utilized. Major (Clavien >2) post-operative complications occurred in two (1.9%) patients. At a median follow-up of 15.1 (IQR 5.0-30.4) months, 94 (89.5%) cases were surgically successful. Conclusions: RUR may be performed with good intermediate-term outcomes for patients with recurrent strictures after prior failed endoscopic and/or surgical management.

Perioperative Complications and Oncologic Outcomes of Nephrectomy Following Immune Checkpoint Inhibitor Therapy: A Multicenter Collaborative Study.

BACKGROUND: Immune checkpoint inhibitors (ICIs) are now a mainstay of metastatic renal cell carcinoma (RCC) management with five current Food and Drug Administration-approved regimens. However, data regarding nephrectomy outcomes following an ICI are limited. OBJECTIVE: To evaluate the safety and outcomes of nephrectomy following an ICI. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was performed of patients with primary locally advanced or metastatic RCC undergoing nephrectomy following an ICI in five US academic centers between January 2011 and September 2021. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Clinical data, perioperative outcomes, and 90-d complications/readmissions were recorded and evaluated by univariate and logistic regression models. Recurrence-free and overall survival probabilities were estimated by the Kaplan-Meier method. RESULTS AND LIMITATIONS: A total of 113 patients with a median (interquartile range) age of 63 (56-69) yr were included. The main ICI regimens were nivolumab ± ipilimumab (n = 85) and pembrolizumab ± axitinib (n = 24). Risk groups included 95% intermediate- and 5% poor-risk patients. Surgical procedures were 109 radical and four partial nephrectomies, including 60 open, 38 robotic, and 14 laparoscopic with five (10%) conversions. Two intraoperative complications were reported (bowel and pancreatic injury). The median operative time, estimated blood loss, and hospital stay were 3 h, 250 ml, and 3 d, respectively. A complete pathologic response (ypT0N0) was noted in six (5%) patients. The 90-d complication rate was 24%, with 12 (11%) patients requiring readmission. On a multivariable analysis, two or more risk factors (odds ratio [OR] 2.91, 95% confidence interval [CI]: 1.09, 7.42) and pathologic T stage ≥T3 (OR 4.21, 95% CI: 1.13-15.8) were independently associated with a higher 90-d complication rate. The 3-yr estimated overall survival and recurrence-free survival rates were 82% and 47%, respectively. Limitations include the retrospective nature and heterogeneous cohort in terms of clinicopathologic characteristics and ICI regimens received. CONCLUSIONS: Nephrectomy following ICI therapy is feasible and a potential consolidative therapy option in select patients. Further research in the neoadjuvant setting is also warranted. PATIENT SUMMARY: This study evaluates the outcomes of kidney surgery following immune checkpoint inhibitor therapy (mainly nivolumab and ipilimumab or pembrolizumab and axitinib) for patients with advanced kidney cancer. We utilized data from five academic centers across the USA and found that surgery in this setting did not have more complications or returns to the hospital than similar surgeries, indicating that it is a safe and feasible procedure at this time.

Technical surgical skill assessment of neurovascular bundle dissection and urinary continence recovery after robotic-assisted radical prostatectomy.

Purpose: To examine the association between the quality of neurovascular bundle dissection and urinary continence recovery after robotic-assisted radical prostatectomy. Materials and Methods: Patients who underwent RARPs from 2016 to 2018 in two institutions with ≥1-year postoperative follow-up were included. The primary outcomes were time to urinary continence recovery. Surgical videos were independently assessed by 3 blinded raters using the validated Dissection Assessment for Robotic Technique (DART) tool after standardized training. Cox regression was used to test the association between DART scores and urinary continence recovery while adjusting for relevant patient features. Results: 121 RARP performed by 23 surgeons with various experience levels were included. The median follow-up was 24 months (95% CI 20 - 28 months). The median time to continence recovery was 7.3 months (95% CI 4.7 - 9.8 months). After adjusting for patient age, higher scores of certain DART domains, specifically tissue retraction and efficiency, were significantly associated with increased odds of continence recovery (p<0.05). Conclusions: Technical skill scores of neurovascular bundle dissection vary among surgeons and correlate with urinary continence recovery. Unveiling the specific robotic dissection skillsets which impact patient outcomes has the potential to focus surgical training.

A Preoperative Nomogram to Predict Renal Function Insufficiency for Cisplatin-based Adjuvant Chemotherapy Following Minimally Invasive Radical Nephroureterectomy (ROBUUST Collaborative Group).

BACKGROUND: Postoperative renal function impairment represents a main limitation for delivering adjuvant chemotherapy after radical nephroureterectomy (RNU). OBJECTIVE: To create a model predicting renal function decline after minimally invasive RNU. DESIGN, SETTING, AND PARTICIPANTS: A total of 490 patients with nonmetastatic UTUC who underwent minimally invasive RNU were identified from a collaborative database including 17 institutions worldwide (February 2006 to March 2020). Renal function insufficiency for cisplatin-based regimen was defined as estimated glomerular filtration rate (eGFR) <50 ml/min/1.73 m2 at 3 mo after RNU. Patients with baseline eGFR >50 ml/min/1.73 m2 (n = 361) were geographically divided into a training set (n = 226) and an independent external validation set (n = 135) for further analysis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, a nomogram to predict postoperative eGFR <50 ml/min/1.73 m2 was built based on the coefficients of the least absolute shrinkage and selection operation (LASSO) logistic regression. The discrimination, calibration, and clinical use of the nomogram were investigated. RESULTS AND LIMITATIONS: The model that incorporated age, body mass index, preoperative eGFR, and hydroureteronephrosis was developed with an area under the curve of 0.771, which was confirmed to be 0.773 in the external validation set. The calibration curve demonstrated good agreement. Besides, the model was converted into a risk score with a cutoff value of 0.583, and the difference between the low- and high-risk groups both in overall death risk (hazard ratio [HR]: 4.59, p < 0.001) and cancer-specific death risk (HR: 5.19, p < 0.001) was statistically significant. The limitation mainly lies in its retrospective design. CONCLUSIONS: A nomogram incorporating immediately available clinical variables can accurately predict renal insufficiency for cisplatin-based adjuvant chemotherapy after minimally invasive RNU and may serve as a tool facilitating patient selection. PATIENT SUMMARY: We have developed a model for the prediction of renal function loss after radical nephroureterectomy to facilitate patient selection for perioperative chemotherapy.

Single-stage Xi® robotic radical nephroureterectomy for upper tract urothelial carcinoma: surgical technique and outcomes.

BACKGROUND: Radical nephroureterectomy (RNU) represents the standard of care for high grade upper tract urothelial carcinoma (UTUC). Open and laparoscopic approaches are well-established treatments, but evidence regarding robotic RNU is growing. The introduction of the Xi® system facilitates the implementation of this multi-quadrant procedure. The aim of this video-article is to describe the surgical steps and the outcomes of Xi® robotic RNU. METHODS: Single stage Xi® robotic RNU without patients repositioning and robot re-docking were done between 2015 and 2019 and collected in a large worldwide multi-institutional study, the ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST). Institutional review board approval and data share agreement were obtained at each center. Surgical technique is described in detail in the accompanying video. Descriptive statistics of baseline characteristics and surgical, pathological, and oncological outcomes were analyzed. RESULTS: Overall, 148 patients were included in the analysis; 14% had an ECOG >1 and 68.2% ASA ≥3. Median tumor dimension was 3.0 (IQR:2.0-4.2) cm and 34.5% showed hydronephrosis at diagnosis. Forty-eight% were cT1 tumors. Bladder cuff excision and lymph node dissection were performed in 96% and 38.1% of the procedures, respectively. Median operative time and estimated blood loss were 215.5 (IQR:160.5-290.0) minutes and 100.0 (IQR: 50.0-150.0) mL, respectively. Approximately 56% of patients took opioids during hospital stay for a total morphine equivalent dose of 22.9 (IQR:16.0-60.0) milligrams equivalent. Post-operative complications were 26 (17.7%), with 4 major (2.7%). Seven patients underwent adjuvant chemotherapy, with median number of cycles of 4.0 (IQR:3.0-6.0). CONCLUSIONS: Single stage Xi® RNU is a reproducible and safe minimally invasive procedure for treatment of UTUC. Additional potential advantages of the robot might be a wider implementation of LND with a minimally invasive approach.

Robot-Assisted Laparoscopic Distal Ureteroureterostomy for Distal Benign Ureteral Strictures with Long-Term Follow-Up.

Objectives: To demonstrate feasibility of robot-assisted laparoscopic (RAL) ureteroureterostomy (UU) for benign distal ureteral strictures (DUS) in our robotic reconstruction series with long-term follow-up. Patients and Methods: In a retrospective review of our prospectively maintained RAL ureteral reconstruction database, we followed patients between June 2012 and February 2019 who underwent a UU for DUS. In addition to patient demographics, we recorded the etiology, stricture length, and recurrence rates. Recurrence was defined as findings of recurrent or persistent obstruction by postoperative mercaptoacetyltriglycine diuretic renal scan or the need for additional intervention with ureteral drainage or revisional surgery. Results: We identified 22 patients who underwent a RAL-UU for DUS of benign etiologies. Median age was 42 years (interquartile range [IQR] 39-57) and 20 of 22 patients (90.1%) were women. Median stricture length was 1.5 cm (IQR 1-2). Iatrogenic surgical injury was noted in 16 patients (73%). All ureteral reconstruction was performed using RAL. Postoperative imaging consisted of renal ultrasonography, diuretic renal scan, or cross-sectional radiology within 3 months of the index operation. Further imaging was dependent on clinical judgment. Twenty patients (90.1%) had success with median follow-up time of 54.6 months with two recurrences necessitating RAL ureteroneocystostomy (UNC). Conclusion: RAL-UU for DUS is technically viable and shows promising efficacy in properly selected patients. This technique may serve a niche for preserving the natural anatomical drainage of the bladder and ureter in addition to obviating the sequela of vesicoureteral reflux as seen in UNC.

Management of symptomatic adult penile urethral arteriovenous malformation.

We present the Case of a 23-year-old male with a history of recurrent spontaneous urethral bleeding due to an arteriovenous malformation (AVM) of his corpus spongiosum which abutted his penile urethra. AVMs are often congenital but can also be related to prior trauma. The literature on male genital AVMs is primarily limited to pediatric AVMs of the scrotum or glans penis with one report of adult urethral AVM in the setting of known trauma. We describe a novel presentation of atraumatic adult male genital AVM treated by surgical repair with resolution of bleeding.

Pathological characteristics of the large renal mass: potential implication for clinical role of renal biopsy.

INTRODUCTION: To assess whether patients with a large renal mass, treated by radical nephrectomy (RN), could have benefited from preoperative renal mass biopsy (RMB). The decision to perform partial nephrectomy (PN) for an organ-confined > 4 cm renal mass can be complex. Albeit often feasible, oncologic safety of PN in this cohort is debated. Yet, a significant portion of large renal masses that undergo RN prove benign or indolent, indicating a potential role for RMB to guide nephron preservation. MATERIALS AND METHODS: We queried prospectively maintained databases from three institutions to identify patients who underwent RN for localized > 4 cm renal mass. We excluded patients with nodal or distant metastases. Multivariable analysis assessed how clinicopathologic variables, mass anatomic complexity, and patient comorbidities related to the likelihood of harboring an indolent neoplasm. RESULTS: A total of 702 patients underwent RN for localized > 4 cm renal mass (median tumor size 7.0 cm (IQR 5.5-9.2); 12.8% (n = 90) of patients were diagnosed with oncocytoma/oncocytic neoplasm (n = 27, 3.8%) or chromophobe RCC (n = 63, 9.0%). When stratified by tumor size, indolent tumors comprised 10.1% of 4-7 cm masses, 15.6% of ≥ 7-10 cm masses, and 17.3% of ≥ 10 cm tumors. Upon multivariate analysis, younger age was associated with indolent tumors (p = 0.04, OR 0.97, 95% CI 0.94-0.99). CONCLUSIONS: Approximately 1 in 8 patients with a renal mass > 4 cm harbored benign or low risk indolent potential lesions and were associated with younger age. As such, patients with large renal masses for whom risk trade-offs between PN and RN are unclear, present a unique opportunity for greater utilization of RMB.

Cystoscopy and Systematic Bladder Tissue Sampling in Predicting pT0 Bladder Cancer: A Prospective Trial.

PURPOSE: Concern for discordance between clinical staging and final pathology drives current management of patients deemed appropriate candidates for radical cystectomy. Therefore, we set out to prospectively investigate reliability and shortcomings of cystoscopic evaluation in radical cystectomy candidates. MATERIALS AND METHODS: Patients undergoing radical cystectomy for urothelial carcinoma were enrolled in a prospective single-arm study to evaluate reliability of Systematic Endoscopic Evaluation in predicting pT0 urothelial carcinoma (NCT02968732). Systematic Endoscopic Evaluation consisted of cystoscopy and tissue sampling at the time of radical cystectomy. Systematic Endoscopic Evaluation results were compared to radical cystectomy pathology. The primary end point was the negative predictive value of Systematic Endoscopic Evaluation findings in predicting radical cystectomy pathology. RESULTS: A total of 61 patients underwent Systematic Endoscopic Evaluation and radical cystectomy. Indications included muscle invasive bladder cancer in 42 (68.9%) and high risk nonmuscle invasive bladder cancer in 19 (31.1%). In all, 38 (62.3%, 90.5% of patients with muscle invasive bladder cancer) received neoadjuvant chemotherapy. On Systematic Endoscopic Evaluation, 31 (50.8%) patients demonstrated no visual nor biopsy-based evidence of disease (seeT0), yet 16/31 (51.6%) harbored residual disease (>pT0), including 8 (8/31, 25.8%) with residual ≥pT2 disease upon radical cystectomy. The negative predictive value of Systematic Endoscopic Evaluation predicting a pT0 bladder was 48.4% (CI 30.2-66.9), which was below our prespecified hypothesis. Therefore, the trial was stopped for futility. CONCLUSIONS: Approximately 1 of 4 patients with seeT0 at the time of radical cystectomy harbored residual muscle invasive bladder cancer. These prospective data definitively confirm major limitations of endoscopic assessment for pT0 bladder cancer. Future work should focus on novel imaging and biomarker strategies to optimize evaluations before radical cystectomy for improved decision making regarding bladder preservation.

Nephrobiliary fistula resulting from a gunshot wound in a young healthy male: A case report.

Biliary fistulas are most commonly caused by cholelithiasis. Other causes include malignancies and peptic ulcer disease. A biliary fistula caused by a penetrating trauma is a rare entity, and a post-traumatic biliary fistula to the renal collecting system is extremely uncommon. We present an extremely rare case of a post-traumatic nephrobiliary fistula incurred after penetrating trauma that was successfully treated with endoscopic retrograde cholangiopancreatography (ERCP), biliary stents, and percutaneous drainage.

Robotic Ureteral Reconstruction in Patients with Radiation-Induced Ureteral Strictures: Experience from the Collaborative of Reconstructive Robotic Ureteral Surgery.

Objectives: Management of radiation-induced ureteral stricture (RIUS) is complex, requiring chronic drainage or morbid definitive open reconstruction. Herein, we report our multi-institutional comprehensive experience with robotic ureteral reconstruction (RUR) in patients with RIUSs. Patients and Methods: In a retrospective review of our multi-institutional RUR database between January 2013 and January 2020, we identified patients with RIUSs. Five major reconstruction techniques were utilized: end-to-end (anastomosing the bladder to the transected ureter) and side-to-side (anastomosing the bladder to an anterior ureterotomy proximal to the stricture without ureteral transection) ureteral reimplantation, buccal or appendiceal mucosa graft ureteroplasty, appendiceal bypass graft, and ileal ureter interposition. When necessary, adjunctive procedures were performed for mobility (i.e., psoas hitch) and improved vascularity (i.e., omental wrap). Outcomes of surgery were determined by the absence of flank pain (clinical success) and absence of obstruction on imaging (radiological success). Results: A total of 32 patients with 35 ureteral units underwent RUR with a median stricture length of 2.5 cm (interquartile range [IQR] 2-5.5). End-to-end and side-to-side reimplantation techniques were performed in 21 (60.0%) and 8 (22.9%) RUR cases, respectively, while 4 (11.4%) underwent an appendiceal procedure. One patient (2.9%) required buccal mucosa graft ureteroplasty, while another needed an ileal ureter interposition. The median operative time was 215 minutes (IQR 177-281), estimated blood loss was 100 mL (IQR 50-150), and length of stay was 2 days (IQR 1-3). One patient required repair of a small bowel leak. Another patient died from a major cardiac event and was excluded from follow-up calculations. At a median follow-up of 13 months (IQR 9-22), 30 ureteral units (88.2%) were clinically and radiologically effective. Conclusion: RUR can be performed in patients with RIUSs with excellent outcomes. Surgeons must be prepared to perform adjunctive procedures for mobility and improved vascularity due to poor tissue quality. Repeat procedures for RIUSs heighten the risk of necrosis and failure.

Intermediate-term outcomes after robotic ureteral reconstruction for long-segment (≥4 centimeters) strictures in the proximal ureter: A multi-institutional experience.

PURPOSE: To report our intermediate-term, multi-institutional experience after robotic ureteral reconstruction for the management of long-segment proximal ureteral strictures. MATERIALS AND METHODS: We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all patients who underwent robotic ureteral reconstruction for long-segment (≥4 centimeters) proximal ureteral strictures between August 2012 and June 2019. The primary surgeon determined the specific technique to reconstruct the ureter at time of surgery based on the patient's clinical history and intraoperative findings. Our primary outcome was surgical success, which we defined as the absence of ureteral obstruction on radiographic imaging and absence of obstructive flank pain. RESULTS: Of 20 total patients, 4 (20.0%) underwent robotic ureteroureterostomy (RUU) with downward nephropexy (DN), 2 (10.0%) underwent robotic ureterocalycostomy (RUC) with DN, and 14 (70.0%) underwent robotic ureteroplasty with buccal mucosa graft (RU-BMG). Median stricture length was 4 centimeters (interquartile range [IQR], 4-4; maximum, 5), 6 centimeters (IQR, 5-7; maximum, 8), and 5 centimeters (IQR, 4-5; maximum, 8) for patients undergoing RUU with DN, RUC with DN, and RU-BMG, respectively. At a median follow-up of 24 (IQR, 14-51) months, 17/20 (85.0%) cases were surgically successful. Two of four patients (50.0%) who underwent RUU with DN developed stricture recurrences within 3 months. CONCLUSIONS: Long-segment proximal ureteral strictures may be safely and effectively managed with RUC with DN and RU-BMG. Although RUU with DN can be utilized, this technique may be associated with a higher failure rate.

Multi-institutional Experience Comparing Outcomes of Adult Patients Undergoing Secondary Versus Primary Robotic Pyeloplasty.

OBJECTIVE: To describe surgical techniques and peri-operative outcomes with secondary robotic pyeloplasty (RP), and compare them to those of primary RP. METHODS: We retrospectively reviewed our multi-institutional, collaborative of reconstructive robotic ureteral surgery (CORRUS) database for all consecutive patients who underwent RP between April 2012 and September 2019. Patients were grouped according to whether they underwent a primary or secondary pyeloplasty (performed for a recurrent stricture after previously failed pyeloplasty). Perioperative outcomes and surgical techniques were compared using nonparametric independent sample median tests and chi-square tests; P < .05 was considered significant. RESULTS: Of 158 patients, 28 (17.7%) and 130 (82.3%) underwent secondary and primary RP, respectively. Secondary RP, compared to primary RP, was associated with a higher median estimated blood loss (100.0 vs 50.0 milliliters, respectively; P < .01) and longer operative time (188.0 vs 136.0 minutes, respectively; P = .02). There was no difference in major (Clavien >2) complications (P = .29). At a median follow-up of 21.1 (IQR: 11.8-34.7) months, there was no difference in success between secondary and primary RP groups (85.7% vs 92.3%, respectively; P = .44). Buccal mucosa graft onlay ureteroplasty was performed more commonly (35.7% vs 0.0%, respectively, P < .01) and near-infrared fluorescence imaging with indocyanine green was utilized more frequently (67.9% vs 40.8%, respectively; P < .01) for secondary vs primary repair. CONCLUSION: Although performing secondary RP is technically challenging, it is a safe and effective method for recurrent ureteropelvic junction obstruction after a previously failed pyeloplasty. Buccal mucosa graft onlay ureteroplasty and utilization of near-infrared fluorescence with indocyanine green may be particularly useful in the re-operative setting.

A Multi-Institutional Experience With Robotic Appendiceal Ureteroplasty.

OBJECTIVE: To report a multi-institutional experience with robotic appendiceal ureteroplasty. METHODS: This is a retrospective review of 13 patients undergoing right appendiceal flap ureteroplasty at 2 institutions between April 2016 and October 2019. The primary endpoint was surgical success defined by the absence of flank pain and radiographic evidence of ureteral patency. RESULTS: Eight of 13 (62%) underwent appendiceal onlay while 5/13 (38%) underwent appendiceal interposition. Mean length of stricture was 6.5 cm (range 1.5-15 cm) affecting anywhere along the right ureter. Mean operative time was 337 minutes (range 206-583), mean estimated blood loss was 116 mL (range 50-600), and median length of stay was 2.5 days (range 1-9). Balloon dilation was required in 1/12 (8%). One patient died on postoperative day 0 due to a sudden cardiovascular event. Otherwise, there were no complications (Clavien-Dindo > 2) within 30 days from surgery. At a mean follow up of 14.6 months, 11/12 (92%) were successful. CONCLUSION: Robotic appendiceal ureteroplasty for right ureteral strictures is a versatile technique with high success rates across institutions.

Intermediate-term Urinary Function and Complication Outcomes After Robot-Assisted Simple Prostatectomy.

OBJECTIVE: To assess the incidence of delayed complications after robot-assisted simple prostatectomy and evaluate postoperative lower urinary tract symptoms (LUTS) as a function of time with intermediate-term follow-up. METHODS: We retrospectively reviewed 150 patients who underwent robot-assisted simple prostatectomy between May, 2013 and January, 2019. Indication for surgery was bothersome LUTS refractory to medical management and prostate volume ≥80 milliliters. The severity of LUTS was assessed using the International Prostate Symptom Score (IPSS) and quality of life (QOL) score. One-way analysis of variance test with post hoc Tukey's honest significant difference test was used to compare postoperative IPSS and QOL scores as a function of time; P <.05 was considered significant. RESULTS: At a mean ± SD follow up of 31.3 ± 18.2 months, none of the patients developed a bladder neck contracture and none of the patients required reoperation for LUTS. Postoperatively, IPSS and QOL scores decreased with an increasing duration of follow up (P <.001). Mean IPSS and QOL scores improved between 2 weeks and 3 months postoperatively (P = .027 and P = .006, respectively). After 3 months postoperatively, mean IPPS and QOL scores stabilized and remained unchanged up to 36 months of follow-up (all P >.05). CONCLUSION: Robotic simple prostatectomy is associated with a low incidence of delayed complications at a mean of 31.3 months postoperatively. After robotic simple prostatectomy, urinary function outcomes improve in the early postoperative period with maximal improvement occurring at 3 months. Excellent urinary function outcomes are durable up to at least 36 months postoperatively.

Ureteral Reimplantation via Robotic Nontransecting Side-to-Side Anastomosis for Distal Ureteral Stricture.

Objective: To describe a novel technique of ureteral reimplantation through robotic nontransecting side-to-side anastomosis. Although the standard approach to ureteroneocystostomy has a high rate of success, it involves transection of the ureter that may impair vascularity and contribute to recurrent strictures. Our method seeks to maximally preserve distal ureteral blood flow that may reduce this risk. Materials and Methods: We retrospectively reviewed a multi-institutional ureteral reconstruction database to identify patients who underwent this operation between 2014 and 2018, analyzing perioperative and postoperative outcomes. Results: Our technique was utilized in 16 patients across three U.S. academic institutions. Median operative time and estimated blood loss were 178 minutes (interquartile range [IQR] 150-204) and 50 mL (IQR 38-100), respectively. The median length of stay was 1 day (IQR 1-2). No intraoperative complications or postoperative complications with Clavien score ≥3 were reported. Postoperatively, 15 of 16 (93.8%) patients reported clinical improvement in flank pain, and all patients who underwent follow-up imaging had radiographic improvement with decrease in hydronephrosis at a median follow-up of 12.5 months. Conclusions: Ureteral reimplantation through a robotic nontransecting side-to-side anastomosis is a feasible and effective operation for distal ureteral stricture that may have advantages over the standard of care transecting ureteroneocystostomy.

Robot-assisted distal ureteral reconstruction for benign pathology: Current state.

Distal ureteral reconstruction for benign pathologies such as stricture disease or iatrogenic injury has posed a challenge for urologist as endoscopic procedures have poor long-term outcomes, requiring definitive open reconstruction. Over the past decade, there has been an increasing shift towards robot-assisted laparoscopy (RAL) with multiple institutions reporting their outcomes. In this article, we reviewed the current literature on RAL distal ureteral reconstruction, focusing on benign pathologies only. We present peri-operative data and outcomes on the most common technique, ureteral reimplantation, as well as adjunct procedures such as psoas hitch and Boari flap. Additionally, we present alternative techniques reported in the literature with some technical considerations. Lastly, we describe the outcomes of the comparative studies between open, laparoscopy, and RAL. Although the body of literature in this field is limited, RAL reconstruction of the distal ureter appears to be safe, feasible, and with some advantages over the traditional open approach.

Functional Parenchymal Volume-based Spectrum Score Is Able to Quantify Ischemic Injury After Partial Nephrectomy.

OBJECTIVE: To externally validate the Spectrum Score (SS) using a modified calculation based on functional parenchymal volumes (FPVs) instead of renal scans. The SS quantifies acute ischemic injury in the ipsilateral kidney after partial nephrectomy. However, this metric requires renal split function assessment via renal scans, which may be unavailable in routine practice. METHODS: We retrospectively reviewed patients with a solitary renal mass and contralateral kidney who underwent partial nephrectomy at our institution between 2015 and 2017. FPVs were calculated using cylindrical volume approximation and used to quantitate relative renal function. Based on renal split function and parenchyma preserved, we determined creatinineideal, assuming no ipsilateral kidney ischemic injury, and creatinineworst-case, assuming temporary ipsilateral kidney nonfunction. FPV-based SS was defined as follows: (observed peak creatinine-creatinineideal)/(creatinineworst-case-creatinineideal). Functional recovery was defined as follows: (% function saved)/(% parenchyma preserved). Factors associated with FPV-based SS and functional recovery were assessed using linear regression. RESULTS: We assessed 174 patients with a median renal mass size of 2.7 cm (IQR 2.0-3.6), warm ischemia time of 26.0 minutes (IQR 19.0-34.3), and parenchyma preservation of 92.6% (IQR 80.8-100). Preoperative ipsilateral kidney % split function (P = .003), preoperative ipsilateral kidney glomerular filtration rate (P = .045), and warm ischemia time (P = .005) were independently associated with FPV-based SS. Only FPV-based SS (P<.001) was independently associated with functional recovery. CONCLUSION: The FPV-based SS, which does not require renal scans, quantifies acute ipsilateral renal dysfunction and predicts functional recovery after partial nephrectomy.