Perioperative, Oncological, and Functional Outcomes Between Robot-Assisted Laparoscopic Prostatectomy and Open Radical Retropubic Prostatectomy: A Randomized Clinical Trial.

PURPOSE: Limited high-quality studies have compared robot-assisted laparoscopic prostatectomy (RALP) vs open retropubic radical prostatectomy. We sought to compare their postoperative outcomes in a randomized setting. MATERIALS AND METHODS: In a single center, 354 men with newly diagnosed prostate cancer were assessed for eligibility; 342 were randomized (1:1). The primary outcome was 90-day complication rates. Functional outcomes and quality of life were assessed over 18 months, and oncological outcomes, biochemical recurrence-free survival, and additional treatment over 36 months. RESULTS: From 2014 to 18, 327 patients underwent surgery (retropubic radical prostatectomy = 156, RALP = 171). Complications occurred in 27 (17.3%) vs 19 (11.1%; P = .107). Patients undergoing RALP experienced lower median bleeding (250.0 vs 719.5 mL; P < .001) and shorter hospitalization time. Urinary EPIC (Expanded Prostate Cancer Index Composite) median scores were better for RALP over 18 months, with higher continence rate at 3 months (80.5% vs 64.7%; P = .002), 6 months (90.1% vs 81.6%; P = .036) and 18 months (95.4% vs 78.8%; P < .001). Sexual EPIC and Sexual Health Inventory for Men median scores were higher with RALP up to 12 months, while the potency rate was superior at 3 months (23.9% vs 5.3%; P = .001) and 6 months (30.6% vs 6.9%; P < .001). Quality of life over the 18 months and oncological outcomes over 36 months were not significantly different between arms. CONCLUSIONS: Complications at 90 days were similar. RALP showed superior sexual outcomes at 1 year, improved urinary outcomes at 18 months, and comparable oncological outcomes at 36 months.

Cardiovascular and Thromboembolic Events in Patients With Localized Prostate Cancer Receiving Intensified Neoadjuvant Androgen Deprivation: A Systematic Review and Meta-Analysis.

Several phase II trials have investigated neoadjuvant novel androgen receptor signaling inhibitors (ARSIs) in combination with androgen deprivation therapy (ADT) followed by radical prostatectomy (RP) in prostate cancer (PC) patients. However, data regarding complications of intense hormone therapy and surgical complications are scarce. Our objective was to evaluate the occurrence of cardiovascular (CV) and thromboembolic (TE) adverse events (AE) in patients with localized PC who have received intense neoadjuvant ADT followed by prostatectomy. A comprehensive search in MEDLINE, Embase, Scopus and conference abstracts was performed. The strategies were developed and applied for each electronic database on March 7th, 2023. Eligible studies included randomized and single-arm trials testing ARSIs prior to prostatectomy that adequately reported safety data regarding CV and TE AE, peri-operative complications, and mortality during therapy. Pooled incidence (PI) of AE with 95% confidence interval (95% CI) was estimated using a random effects model. Quality assessment and reporting followed Cochrane Collaboration Handbook and PRISMA guidelines. PROSPERO: CRD42022344104. Nine randomized controlled trials and three single-arm phase II trials were included, comprising 702 patients (702 patients for CV AE and 522 for perioperative complications). The neoadjuvant regimen was classified as monotherapy with ARSI (100 patients), combination therapy with ADT + ARSI (383 patients), or ADT + ARSI + ARSI (219 patients). The PI of TE within the perioperative interval was 4.2% (95% CI = 2.6%-6.6%, I2 = 0.0%, P = .65), and the PI for CV AE was 4.6% (95% CI = 3.1%-6.7%, I2 = 0.0%, P = .71). Seven deaths were reported, resulting in a PI of 2.2% (95% CI = 1.3%-3.8%, I2 = 0.0%, P = .99), of which two were considered treatment-related and occurred within the perioperative period. The PI of hypertension grade 3-5 was 7.3% (95% CI = 4.8%-11.0%, I2 = 38.8%, P = .04). CV and TE AE associated with intense neoadjuvant hormone therapy in patients with localized PC can occur in up to 4.6% of cases. Our data warns for further assessment of thrombotic risk and prophylactic anticoagulation in this setting.

First case of robot-assisted radical cystectomy and intracorporeal neobladder reconstruction with the Hugo RAS system: step-by-step surgical setup and technique.

Robotic assisted radical cystectomy (RARC) is a standard option for the treatment of bladder cancer. Currently, novel platforms are entering the market and the Hugo RAS (Medtronic, Minneapolis, MN, USA) is a new system consisting of an open console with 3D-HD screen and a multi-modular fashion. Even if several series are already available for radical prostatectomy, to now a full description of RARC performed with Hugo RAS is still lacking. We report the first case of RARC with intracorporeal neobladder performed with the Hugo RAS-and another case of RARC with ureterostomy. Both patients were affected by MIBC. Case 1 was a 61-year-old patient without comorbidities (CCI 4), in which a Bordeaux ileal neobladder was scheduled after previous NAC. The second was the case of a 70-year-old one with CCI 7 and BMI 35; in this case, a ureterostomy was planned. Details of the robotic system: one 11 mm endoscope port was placed on the midline 2 cm above the umbilicus. Another two 8 mm robotic ports were symmetrically placed under vision on a transversal line-located 1 cm below the umbilicus. A third robotic port was positioned on the left side in a W configuration. All ports were located at least 9 cm between each other. Finally, two assistant ports were positioned in the right abdominal site. All arm-carts were parked 45-60 cm from the operative bed, before the docking process begins. Three arm-carts were parked on the left side, the assistant and the scrub nurse worked on the right side, while the energy tower stayed at the foot of the bed, according to the previous description of Hugo RAS robotic radical prostatectomy. The endoscope arm-cart is docked first, then the adjacent left carts are docked; finally, the surgeon's right-hand cart is docked from the right side of the bed. The docking angles and tilt we applied were: endoscope: 175°; minus 45°; surgeon left hand 140°; minus 30°; surgeon right hand 225°; minus 30°; fourth arm 125°; plus 15°. The instruments we used were those fitting our conventional four-instrument setup for RARC: monopolar shears, Maryland forceps, needle driver and Cadiere as the fourth arm. The procedures were completed without technical errors or technological failures-requiring a change in surgical strategy. Docking time was approximately 35 min; console time up to urethral dissection was 150 and 140 min in Case 1 and 2. The time for pelvic nodal dissection was approximately 37 min for both. The multi-modularity fashion of the Hugo RAS allowed an easy management of the bowel in Case 1; the absence of robotic staplers required the use of the laparoscopic ones, managed by an adjunctive assistant with room within the cart. In conclusion, RARC with the Hugo RAS is a feasible procedure able to reproduce all surgical steps without critical errors or complications requiring a change in surgical planning. Urinary diversion with intracorporeal reconstruction is feasible as well, with adequate preliminary outcomes.

Histological Variants of Urothelial Carcinoma Predict No Response to Neoadjuvant Chemotherapy.

BACKGROUND: Platinum-based neoadjuvant chemotherapy (NAC) in muscle-invasive urothelial bladder cancer (MIBC) has been adopted as a standard of care related to better survival outcomes. However, there is a considerable number of patients who do not respond, experiencing toxicity and delay in the surgical treatment. Our aim is to find biomarkers of response that could be easily adopted in the clinical practice. METHODS: Between January 2009 and July 2016, 52 patients with MIBC were submitted to radical cystectomy after NAC. A tissue microarray containing 25 cases, who met the inclusion criteria was built for immunohistochemical analysis of Cytokeratins 5/6, 7, and 20, GATA3, Her2, EGFR, p63, p53, Carbonic-anhydrase IX (CAIX), MLH1, MSH2, MSH6, and PMS2. The surgery was performed in a mean time of 58.7 (± 21) days after the end of the NAC. Fisher's exact test was used to analyze the relationship between response (≤pT1) and histopathological and immunohistochemical results and Kaplan-Meier curves were designed for survival analysis. RESULTS: Ten (40.0%) patients presented response to NAC. Histological variants of the urothelial carcinoma characterized by squamous, sarcomatous/rhabdoid, plasmacytoid, and micropapillary was present in 36.0% and none responded to NAC (P = .002). CAIX was expressed by 53.3% and none responded to NAC (P= .005). Lymph-node metastasis, divergent differentiation, and expression of cytokeratin 5/6 were related to short cancer specific survival. CONCLUSION: Histological variants and CAIX immune-expression are biomarkers of nonresponse to NAC of MIBC, and might be easily used in the clinical practice to select patients to be submitted to surgery upfront.

Robotic-assisted radical prostatectomy with preceptor's assistance: the training experience and outcomes in South America.

Prostate cancer is currently the second leading cause of cancer deaths in Brazilian men. In 2020, sixty-five thousand new prostate cancer cases were expected in Brazil, and almost 30% of these patients are estimated to be from the northeast region. However, from 75 robotic platforms available in the country, only one is accessible in the state of Ceará since 2015. This study reports the intraoperative, functional, and oncological outcomes of patients who underwent radical prostatectomy for prostate cancer performed by robotic surgeons during a training period supervised by a proctor. We also compared these results with the literature reporting the experience of different Brazilian centers. We retrospectively analyzed prospectively collected data of 58 initial cases of robotic-assisted radical prostatectomy at a private Brazilian hospital in Fortaleza, Ceará. The surgeries were performed by two robotic surgeons during the training period under proctor supervision. We reported the epidemiological and intraoperative data, complications, pathological report, functional and oncological outcomes. The median operative time was 180 min. None of the patients needed conversion or blood transfusion. The pathology report described 21.81% of positive surgical margins (16.27% of all pT2 and 45.45% of all pT3 patients). The median follow-up was 40 months. Biochemical recurrence occurred in 21.73%, continence in 92%, and potency in 79.54%. No major complications (Clavien grades III-V) were reported. In our experience, robotic-assisted radical prostatectomy performed by surgeons training with proctor's assistance is feasible and safe. The operative time, complication rates, functional and oncological outcomes were satisfactory and compatible with the literature.

Case 297: Mucinous Adenocarcinoma of the Prostate.

History A 70-year-old man was referred to our institution with chronic obstructive urinary symptoms and constipation for 2 years before admission. His medical history was unremarkable. Outside laboratory tests revealed an elevated serum prostate-specific antigen level (21.7 ng/mL [normal range, 0.00-4.00 ng/mL]), and urinalysis results were negative. He was admitted for evaluation of possible prostate cancer. The patient reported no specific symptoms of infection and denied fever, dysuria, hematuria, and abdominal pain. He had no family history of prostate cancer. On physical examination, he was afebrile, and the digital rectal examination was not painful. These findings were evidence of an enlarged prostate and a hard multilobulated mass, which was palpable bilaterally. The urologic team performed MRI of the prostate.

Neutrophil-to-Lymphocyte Ratio Predicts Cancer Outcome in Locally Advanced Clear Renal Cell Carcinoma.

BACKGROUND: To evaluate the association of neutrophil-to-lymphocyte ratio (NLR) with recurrence-free survival (RFS) and overall survival (OS) in patients with locally advanced nonmetastatic clear cell renal cell carcinoma (ccRCC) undergoing radical nephrectomy. MATERIAL AND METHODS: We retrospectively identified 880 nephrectomies performed between January 2009 and December 2016 in a single center, reviewed data from 478 radical nephrectomies for kidney tumors and identified 187 patients with locally advanced nonmetastatic ccRCC (pT3-T4 N0M0). NLR was obtained preoperatively and calculated by dividing absolute neutrophil count by absolute lymphocyte count. OS and RFS were evaluated by the Kaplan-Meier method. Cox proportional-hazards regression models were used to evaluate predictors of RFS and OS. RESULTS: Among 187 patients with ccRCC (mean age 63.4 ± 11.5 years; 118 [63.1%] male), the median follow-up was 48.7 months. On univariate analysis, in patients with Fuhrman nuclear grade of differentiation 3-4, the median time to recurrence was significantly shorter with NLR ≥ 4 than < 4 (24 vs. 55 months, P = .045). On multivariable analysis adjusted for NLR ≥ 4, among all variables analyzed (NLR, microvascular invasion, sarcomatoid differentiation, tumor size and body mass index), only nuclear grade of differentiation was an independent predictor of recurrence (hazard ratio 2.18; 95% confidence interval 1.07-4.92, P = .03). The 3-year OS had no statistically significant difference between patients with NLR ≥ 4 or < 4. CONCLUSION: For patients with locally advanced, nonmetastatic ccRCC, RFS was reduced with high nuclear grade of differentiation and high preoperative NLR. These findings suggest an association between higher NLR and worse outcomes in locally advanced ccRCC.

Emerging biomarkers in metastatic urothelial carcinoma: tumour mutational burden, PD-L1 expression and APOBEC polypeptide-like signature in a patient with complete response to anti-programmed cell death protein-1 inhibitor.

Immunotherapy has recently been incorporated into the treatment guidelines for metastatic urothelial carcinoma. Nevertheless, the role of prognostic and predictive biomarkers in this setting is not completely defined. To date, PD-L1 expression and a high tumour mutational burden (TMB) seem to predict better responses to immune checkpoint inhibitors, but patients without these biomarkers may still respond to immunotherapy. There are some caveats regarding these biomarkers, such as lack of standardisation of techniques, tumour heterogeneity and other factors influencing the tumour microenvironment. Genomic signatures are other promising emerging strategies. We hereby discuss the management of a 70-year-old man with a metastatic recurrence of urothelial carcinoma within 1 year after neoadjuvant chemotherapy and radical cystectomy. Tumour next-generation sequencing showed a high TMB and a CD274 (PD-L1) amplification. The patient was treated with pembrolizumab and achieved a complete response.

Noninvasive intracranial pressure real-time waveform analysis monitor during prostatectomy robotic surgery and Trendelenburg position: case report.

Both robotic surgery and head-down tilt increase intracranial pressure by impairing venous blood outflow. Prostatectomy is commonly performed in elderly patients, who are more likely to develop postoperative cognitive disorders. Therefore, increased intracranial pressure could play an essential role in cognitive decline after surgery. We describe a case of a 69-year-old male who underwent a robotic prostatectomy. Noninvasive Brain4careTM intraoperative monitoring showed normal intracranial compliance during anesthesia induction, but it rapidly decreased after head-down tilt despite normal vital signs, low lung pressure, and adequate anesthesia depth. We conclude that there is a need for intraoperative intracranial compliance monitoring since there are major changes in cerebral compliance during surgery, which could potentially allow early identification and treatment of impaired cerebral complacency.

Disruption of miRNA-mRNA Networks Defines Novel Molecular Signatures for Penile Carcinogenesis.

Penile cancer (PeC) carcinogenesis is not fully understood, and no biomarkers are reported in clinical practice. We aimed to investigate molecular signatures based on miRNA and mRNA and perform an integrative analysis to identify molecular drivers and pathways for PeC development. Affymetrix miRNA microarray was used to identify differentially expressed miRNAs (DEmiRs) comparing 11 tumoral tissues (TT) paired with non-neoplastic tissues (NNT) with further validation in an independent cohort (n = 13). We also investigated the mRNA expression of 83 genes in the total sample. Experimentally validated targets of DEmiRs, miRNA-mRNA networks, and enriched pathways were evaluated in silico. Eight out of 69 DEmiRs identified by microarray analysis were validated by qRT-PCR (miR-145-5p, miR-432-5p, miR-487b-3p, miR-30a-5p, miR-200a-5p, miR-224-5p, miR-31-3p and miR-31-5p). Furthermore, 37 differentially expressed genes (DEGs) were identified when comparing TT and NNT. We identified four downregulated DEmiRs (miR-30a-5p, miR-432-5p, miR-487b-3p, and miR-145-5p) and six upregulated DEGs (IL1A, MCM2, MMP1, MMP12, SFN and VEGFA) as potential biomarkers in PeC by their capacity of discriminating TT and NNT with accuracy. The integration analysis showed eight dysregulated miRNA-mRNA pairs in penile carcinogenesis. Taken together, our findings contribute to a better understanding of the regulatory roles of miRNAs and altered transcripts levels in penile carcinogenesis.

MCT1 expression is independently related to shorter cancer-specific survival in clear cell renal cell carcinoma.

Clear cell renal cell carcinoma (ccRCC) has been considered a metabolic disease, with loss of von Hippel-Lindau (VHL) gene and consequent overexpression of hypoxia-inducible factor 1 alpha (HIF-1α), which is central for tumor development and progression. Among other effects, HIF-1α is involved in the metabolic reprogramming of cancer cells towards the Warburg effect involved in tumor cell proliferation, migration and survival. In this context, several proteins are expressed by cancer cells, including glucose and lactate transporters as well as different pH regulators. Among them, monocarboxylate transporters (MCTs) can be highlighted. Our aim is to comprehensively analyze the immunoexpression of MCT1, MCT2, MCT4, CD147, CD44, HIF-1α, GLUT1 and CAIX in ccRCC surgical specimens correlating with classical prognostic factors and survival of patients with long follow-up. Surgical specimens from 207 patients with ccRCC who underwent radical or partial nephrectomy were used to build a tissue microarray. Immunostaining was categorized into absent/weak or moderate/strong and related to all classic ccRCC prognostic parameters. Kaplan-Meier curves were generated to assess overall and cancer-specific survival, and multivariate analysis was performed to identify independent prognostic factors of survival. Multivariate analysis showed that MCT1 together with tumor size and TNM staging, were independently related to cancer-specific survival. MCT1, CD147, CD44 and GLUT1 expression were significantly associated with poor prognostic factors. We show that MCT1 is an independent prognostic factor for cancer-specific survival in ccRCC justifying the use of new target therapies already being tested in clinical trials.

Case 297.

History A 70-year-old man was referred to our institution with chronic obstructive urinary symptoms and constipation for 2 years before admission. His medical history was unremarkable. Outside laboratory tests revealed an elevated serum prostate-specific antigen level (21.7 ng/mL [normal range, 0.00-4.00 ng/mL]), and urinalysis results were negative. He was admitted for evaluation of possible prostate cancer. The patient reported no specific symptoms of infection and denied fever, dysuria, hematuria, and abdominal pain. He had no family history of prostate cancer. On physical examination, he was afebrile, and the digital rectal examination was not painful. These findings were evidence of an enlarged prostate and a hard multilobulated mass, which was palpable bilaterally. The urologic team performed MRI of the prostate (Figs 1-4).

Consensus on Prostate Cancer Treatment of Localized Disease With Very Low, Low, and Intermediate Risk: A Report From the First Prostate Cancer Consensus Conference for Developing Countries (PCCCDC).

PURPOSE: A group of international urology and medical oncology experts developed and completed a survey on prostate cancer (PCa) in developing countries. The results are reviewed and summarized, and recommendations on consensus statements for very low-, low-, and intermediate-risk PCa focused on developing countries were developed. METHODS: A panel of experts developed more than 300 survey questions of which 66 questions concern the principal areas of interest of this paper: very low, low, and intermediate risk of PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up for very low-, low-, and intermediate-risk PCa in areas of limited resources discussed in this manuscript. RESULTS: The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time. CONCLUSION: The voting results and recommendations presented in this document can be used by physicians to support management for very low, low, and intermediate risk of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment for very low, low, and intermediate risk of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.

Evaluation of uro-oncological surgical treatment during the Sars-CoV-2 pandemic in a Brazilian tertiary oncology institution, the new world epicenter

ABSTRACT Introduction: The rapid spread of coronavirus disease 2019 (COVID-19) has dramatic effects on individuals and health care systems. In our institute, a tertiary oncologic public hospital with high surgical volume, we prioritize maintaining cancer treatment as well as possible. The aim of this study is to evaluate if uro-oncological surgeries at pandemic are safe. Materials and Methods: We evaluated patients who underwent uro-oncological procedures. Epidemiological data, information on COVID-19 infection related to surgery and clinical characteristics of non-survival operative patients with COVID-19 infections were analyzed. Results: From 213 patients analyzed, Covid-19 symptoms were noticed in 8 patients at preoperative process or at hospital admission postponing operation; 161 patients were submitted to elective surgery and 44 to emergency surgery. From patients submitted to elective surgeries, we had 1 patient with laboratory confirmation of COVID-19 (0,6%), with mild symptoms and quick discharge. From the urgencies group, we had 6(13%) patients tested positive; 5 were taken to ICU with 4 deaths. Conclusion: Elective uro-oncological procedures at the COVID-19 epidemic period in a COVID-19-free Institute are safe, and patients who need urgent procedures, with a long period of hospitalization, need special care to avoid COVID-19 infection and its outcomes.

Robot-assisted endoscopic inguinal lymphadenectomy: A review of current outcomes.

OBJECTIVE: To review the role of robot-assisted endoscopic inguinal lymphadenectomy (RAIL) in the management of penile cancer. METHODS: A PubMed search for all relevant publications regarding RAIL series up until August 2019 was performed using the keyword "robotic", "inguinal lymph node dissection", and "penile cancer". Weighted mean was calculated in the largest series for all outcomes using the number of patients included in each study as the weighting factor. RESULTS: We identified 23 articles, of note the three largest series that included 102, 27, and 20 RAIL in 51, 14, and 10 patients, respectively. Saphenous vein was spared in 88.93% of RAIL cases in these series and node yield was 11.42 per groin; 35.28% of patients had positive pathological nodes. The weighted mean of operative time was 87.98 min per RAIL and the estimated blood loss was 37.08 mL per patient. The mean length of hospital stay was 1.29 days and the drain was kept in place for 17.02 days; the major complication rate was only 5.31% in these series. The mean follow-up was 33.46 months with a recurrence-free survival of 96.33%. CONCLUSION: The literature regarding RAIL describes promising results, although it has shorter follow-up and higher costs when compared to historically series from the open approach. Initials series reported lower cutaneous complications compared to conventional approach, without compromising oncological outcomes. However, long-term results and larger trials are crucial to validate those findings.

Evaluation of uro-oncological surgical treatment during the Sars-CoV-2 pandemic in a Brazilian tertiary oncology institution, the new world epicenter.

INTRODUCTION: The rapid spread of coronavirus disease 2019 (COVID-19) has dramatic effects on individuals and health care systems. In our institute, a tertiary oncologic public hospital with high surgical volume, we prioritize maintaining cancer treatment as well as possible. The aim of this study is to evaluate if uro-oncological surgeries at pandemic are safe. MATERIALS AND METHODS: We evaluated patients who underwent uro-oncological procedures. Epidemiological data, information on COVID-19 infection related to surgery and clinical characteristics of non-survival operative patients with COVID-19 infections were analyzed. RESULTS: From 213 patients analyzed, Covid-19 symptoms were noticed in 8 patients at preoperative process or at hospital admission postponing operation; 161 patients were submitted to elective surgery and 44 to emergency surgery. From patients submitted to elective surgeries, we had 1 patient with laboratory confirmation of COVID-19 (0,6%), with mild symptoms and quick discharge. From the urgencies group, we had 6(13%)patients tested positive; 5 were taken to ICU with 4 deaths. CONCLUSION: Elective uro-oncological procedures at the COVID-19 epidemic period in a COVID-19-free Institute are safe, and patients who need urgent procedures, with a long period of hospitalization, need special care to avoid COVID-19 infection and its outcomes.

Bilateral nephrectomy robotic-assisted laparoscopic in children with bilateral Wilms' tumor.

Our main objective is to report the feasibility of performing simultaneous robotic-assisted laparoscopic (RAL) right partial nephrectomy with contralateral radical nephrectomy in children with bilateral Wilms' tumor. The RAL right partial nephrectomy and contralateral radical nephrectomy were performed via trans-peritoneal with a four-port approach (five ports in one patient), and the patients were repositioned and draped when moving to the other side. The operative time was 90 min, estimated blood loss was 50 cc. Postoperative length of stay was 2 days. No significant intraoperative or postoperative complications occurred.

Robotic-assisted radical cystectomy: the first multicentric Brazilian experience.

The objective of this study is to report the first multicentric Brazilian series and learning curve of robotic radical cystectomy (RARC) with related intra- and postoperative outcomes. We retrospectively analyzed 37 RARC prospectively collected at four different centers in Brazil, from 2013 to 2019. We analyzed the patient's demographics, pathological tumor, and nodal status, as well as intra- and postoperative outcomes. Statistical analysis was performed with the IBM (SPSS version 25) software. Overall, 86% were male, and the median age was 69 years. 83% had muscle-invasive bladder cancer, and 17% a high-grade, recurrent non-muscle-invasive tumor. The median operative time was 420 min with 300 min as console time. Median blood loss was 350 ml and transfusion rate was 10%. In 68% of the cases, we performed an intracorporeal Bricker urinary diversion, 24% intracorporeal neobladder, and 8% ureterostomy. Six patients (16%) had a Clavien 1-2, 8% had Clavien 3, 2.5% had a Clavien 4, and 5% had Clavien 5. The median length of hospital stay was 7 days. The final pathological exam pointed out pT0 in 16%, pT1 in 8%, pT2 in 32%, ≥ pT3 in 27%, and 16% pTis. 95% had negative surgical margins. The survival at 30, 90, and 180 days was 98%, 95%, and 95%, respectively. To our knowledge, this is the first multicentric series of RARC reporting the learning curve in Brazil; even if still representing a challenging procedure, RARC could be safely and effectively faced by experienced surgeons at centers with high volumes of robotic surgery.

Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes.

BACKGROUND: Robot-assisted laparoscopic radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP which preserves the nerves and vascular structures anterior to the prostate aiming to optimize functional outcomes. OBJECTIVE: To present oncological and functional results of a modified technique for RARP. DESIGN, SETTING, AND PARTICIPANTS: Prospective, noncontrolled case series including 128 consecutive patients undergoing RARP performed by a single surgeon (R.F.C). SURGICAL PROCEDURE: RARP with retrograde release of the neurovascular bundle and preservation of dorsal venous complex. MEASUREMENTS: Potency was defined as a Sexual Health Inventory for Men score of ≥17; continence was defined as use of no pads. Oncological results analyzed were positive surgical margins (PSM) rates and biochemical recurrence (BCR)-free survival. BCR was defined as prostate-specific antigen >0.2ng/ml. Complications were graded according to the Clavien-Dindo classification. RESULTS AND LIMITATIONS: Median patient age was 63.5 yr. Median skin-to-skin time was 78min. Median length of hospital stay was 1 d, with seven patients (5.5%) hospitalized for more than 24h. Median intraoperative bleeding was 200ml and two patients required postoperative blood transfusion (1.6%). Four patients (3.1%) had grade ≥3 complications. Biochemical recurrence (BCR) occurred in nine of 128 patients (7%) and median time to BCR was 6 mo. Overall PSM rate was 13.3% (17 of 128 patients). PSM rate was 9% among patients with pT2 disease (8/89) and 27% in patients with pT3 (9/38). Continence was reached immediately in 85.9% of the patients and 98.4% were continent at1 yr. At 1 mo postoperatively, 60 patients were potent (53%), while 98 patients among 113 (86%) were potent 1 yr after surgery. A limitation of this study is that it was a noncomparative study. CONCLUSIONS: Retrograde release of the neurovascular bundle with preservation of dorsal venous complex during RARP is safe and associated with excellent oncological and functional outcomes. Future comparative studies are needed. PATIENT SUMMARY: Robot-assisted radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP aiming to preserve the nerves and vascular structures anterior to the prostate. We evaluated 128 consecutive patients with clinically localized or locally advanced prostate cancer undergoing RARP with our modified technique of retrograde release of the neurovascular bundles with dorsal vein sparing. We have shown that this technique is safe, effective and associated with early recovery of continence and sexual function after surgery.