Technique and outcomes of robotic-assisted retroperitoneal radical nephrectomy.

Background: Robotic retroperitoneal partial nephrectomy (rRPN) has numerous advantages over transperitoneal surgery, including direct access to the renal hilum and posterior tumors, and avoidance of the peritoneal cavity in patients with a hostile abdomen. Although the use of the retroperitoneal approach has increased over the last decade, there is little literature on robotic retroperitoneal radical nephrectomy (rRRN), which has similar benefits over the transperitoneal approach. The aim of this study was to describe our technique for robotic retroperitoneal nephrectomy (rRN) and assess its feasibility and outcomes at a high-volume center. Methods: A retrospective review of patients who underwent some form of rRN [rRRN, robotic retroperitoneal simple nephrectomy (rRSN), or robotic retroperitoneal nephroureterectomy (rRNU)] at a single institution between 2013 and 2023. Patient characteristics, operative data, and postoperative complication rates were assessed. The technique for rRN was detailed. Results: A total of 13 renal units in 12 patients were included for analysis (7 rRRN, 5 rRSN, 1 rRNU). Median patient age was 64.0 years, and median body mass index (BMI) was 36.0 kg/m2. Indications for retroperitoneal surgery were prior abdominal surgery in all patients, including three with bowel diversions, super morbid central obesity in two patients, and a large ventral hernia in one patient. Median operative time was 213 minutes and median estimated blood loss (EBL) was 85 cc. Median postoperative length of stay (LOS) was 3 days, and only one patient experienced a Clavien-Dindo grade ≥3 complication within 90 days of surgery. Conclusions: The retroperitoneal approach for robotic-assisted nephrectomy is feasible and associated with similar outcomes as the transperitoneal approach. This approach may prove beneficial in select patients with significant prior abdominal surgery including those who are morbidly obese.

Immediate gemcitabine bladder instillation following bladder closure during robotic-assisted radical nephroureterectomy: a multi-institutional report of feasibility and initial outcomes.

Background: Bladder recurrence after radical nephroureterectomy (RNU) is common and randomized data supports utilization of prophylactic intravesical mitomycin to reduce recurrence. Recently, gemcitabine has been shown to be safe and effective at reducing recurrence following transurethral resection of bladder tumors. We sought to evaluate the safety and efficacy of a single, intraoperative gemcitabine instillation immediately following bladder cuff closure during RNU, and to compare outcomes with non-gemcitabine intravesical chemotherapy agents. Methods: We retrospectively reviewed all patients from two high volume centers who underwent robotic-assisted RNU between 2016-2020 and received either 2 g intravesical gemcitabine immediately following bladder cuff closure or non-gemcitabine intravesical chemotherapies [40 mg mitomycin C (MMC) or 50 mg doxorubicin] at the beginning of the procedure. Clinicopathologic factors were compared between cohorts. Bladder recurrence rates were evaluated using the Kaplan-Meier method and log-rank test. Results: During RNU, 24 patients received gemcitabine and 31 patients received non-gemcitabine chemotherapy. In total, 35% (19/55) of patients experienced a bladder cancer recurrence. There was no significant difference in estimated bladder recurrence-free survival (bRFS) between gemcitabine and non-gemcitabine patient cohorts (P=0.64). By 12 months post-surgery, 25% of patients had experienced bladder recurrence. The estimated 1-year bladder RFS survival was 73% for gemcitabine and 76% for non-gemcitabine chemotherapy. Overall survival and cancer-specific survival did not differ between cohorts. No adverse events potentially attributable to the use of gemcitabine were noted within 30 days postoperatively. Conclusions: Gemcitabine instilled immediately following bladder cuff closure during RNU has similar bRFS rates compared to established chemotherapy agents instilled at the start of surgery.

Robotic Partial vs Radical Nephrectomy for Clinical T3a Tumors: A Narrative Review.

Introduction: T3a renal masses include a diverse group of tumors that invade the perirenal and/or sinus fat, pelvicaliceal system, or renal vein. The majority of cT3a renal masses represent renal cell carcinoma (RCC) and have historically been treated with radical nephrectomy (RN) given their aggressive nature. With the adoption of minimally invasive approaches to renal surgery, the combination of improved observation, pneumoperitoneum, and robotic articulation has allowed urologists to consider partial nephrectomy (PN) for more complex tumors. Herein, we review the existing literature regarding robot-assisted PN (RAPN) and robot-assisted RN (RARN) in the management of T3a renal masses. Methods: A literature search was performed using PubMed for articles evaluating the role of RARN and RAPN for T3a renal masses. Search parameters were limited to English language studies. Applicable studies were abstracted and included in this narrative review. Results: T3a RCC caused by renal sinus fat or venous involvement is associated with ∼50% lower cancer-specific survival than those with perinephric fat invasion alone. CT and MRI can both be used to stage cT3a tumors, however, MRI is more accurate when assessing venous involvement. Upstaging to pT3a RCC during RAPN does not confer a worse prognosis than pT3a tumors treated with RARN; however, patients who undergo RAPN for T3a RCC with venous involvement have relatively higher rates of recurrence and metastasis. Intraoperative tools including drop-in ultrasound, near-infrared fluorescence, and 3D virtual models improve the ability to perform RAPN for T3a tumors. In well-selected cases, warm ischemia times remain reasonable. Conclusions: cT3a renal masses represent a diverse group of tumors. Depending on substratification of cT3a, RARN or RAPN can be employed for treatment of such masses.

Significant financial differences of chemical and surgical androgen deprivation in a contemporary cohort.

Background: Androgen deprivation therapy (ADT) remains a cornerstone of treatment for advanced prostate cancer. Few men elect for surgical castration via bilateral orchiectomy. We sought to compare the relative difference in financial charges between chemical and surgical ADT in men. Methods: Billing data was obtained for patients with metastatic prostate cancer receiving chemical ADT and who had bilateral orchiectomy from 2014-2019. Men had chosen intervention based on personal preference. We compared charges of ADT administration for chemical ADT and overall charges for bilateral orchiectomy. We determined the time chemical ADT patient charges surpassed those of surgical charges, as well as the net present value (NPV) of hypothetical savings for electing surgery over various ADT agents. Results: One hundred and thirty-seven patients receiving chemical ADT and 7 patients who had undergone bilateral orchiectomy were analyzed. Median and mean surgical charges were $13,000. By 38 weeks following treatment initiation, 50% of chemical ADT patients had surpassed surgical charges, with 95% at 2 years. The NPV in savings for a median patient varied between ADT agent and was highest at $167,000 for leuprolide. Conclusions: In less than a year, the median chemical ADT patient charges were greater than surgical castration. The NPV of electing surgery over ADT was the highest with leuprolide. Despite under-utilization, surgical castration remains a medically appropriate and cost-effective option for permanent ADT.

Sequential Intravesical Gemcitabine and Docetaxel for bacillus Calmette-Guérin-Naïve High-Risk Nonmuscle-Invasive Bladder Cancer.

PURPOSE: Bacillus Calmette-Guérin (BCG) is currently recommended as adjuvant therapy following complete transurethral resection of bladder tumor for high-risk nonmuscle-invasive bladder cancer (NMIBC). In response to the BCG shortage, gemcitabine plus docetaxel (Gem/Doce) has been utilized at our institution in the BCG-naïve setting. We report the outcomes of patients with high-risk BCG-naïve NMIBC treated with Gem/Doce. MATERIALS AND METHODS: We retrospectively reviewed patients with BCG-naïve high-risk NMIBC treated with Gem/Doce from May 2013 through April 2021. Patients received 6 weekly intravesical instillations of sequential 1 gm gemcitabine and 37.5 mg docetaxel after complete transurethral resection of bladder tumor. Monthly maintenance of 2 years was initiated if disease-free at first followup. The primary outcome was recurrence-free survival. Survival was assessed with the Kaplan-Meier method, indexed from the first Gem/Doce instillation. Adverse events were reported using CTCAE (Common Terminology Criteria for Adverse Events) v5 (National Cancer Institute, Bethesda, Maryland). Differences were assessed with the log-rank test. RESULTS: There were 107 patients with a median followup of 15 months included in the analysis. Patients had high-risk characteristics including 47 with any carcinoma in situ and 55 with T1 disease. Recurrence-free survival was 89%, 85% and 82% at 6, 12 and 24 months, respectively. Recurrence rates were similar between patients with or without carcinoma in situ (p=0.42). No patient had disease progression or died of bladder cancer. One patient underwent cystectomy due to end-stage lower urinary tract symptoms. Overall survival was 84% at 24 months. There were 92 adverse events (1 ≥grade 3), and 4 (4%) patients were unable to receive a full induction course. CONCLUSIONS: Gem/Doce is an effective and well-tolerated therapy for BCG-naïve NMIBC. Further investigation is warranted.

Sequential Intravesical Valrubicin and Docetaxel for the Salvage Treatment of Non-Muscle-Invasive Bladder Cancer.

PURPOSE: Intravesical gemcitabine-docetaxel has emerged as an efficacious and well-tolerated salvage therapy for non-muscle-invasive bladder cancer. However, further rescue therapies are needed for subsequent recurrences or intolerance, particularly when cystectomy is refused or precluded. Valrubicin is a U.S. Food and Drug Administration-approved agent for bacillus Calmette-Guérin unresponsive disease, yet as monotherapy has demonstrated poor efficacy. We report our experience with sequential intravesical valrubicin and docetaxel as a rescue therapy for non-muscle-invasive bladder cancer. MATERIALS AND METHODS: We retrospectively identified all patients with recurrent non-muscle-invasive bladder cancer treated with valrubicin and docetaxel between April 2013 and June 2021. Patients received weekly sequential intravesical instillations of 800 mg valrubicin and 37.5 mg docetaxel for 6 weeks. If disease-free at first follow-up, monthly maintenance of 2 years was initiated. The primary outcome was recurrence-free survival, assessed using the Kaplan-Meier method. RESULTS: The analysis included 75 patients with median follow-up of 21 months (IQR: 13-37). Twelve patients with low-grade disease had a 73% recurrence-free survival at 2 years. Sixty-three patients with recurrent high-grade disease had a 38% 2-year high-grade recurrence-free survival. Forty-two (56%) patients had carcinoma in situ present; recurrence-free survival was similar for those with and without carcinoma in situ (P = .63). Two patients died of metastatic bladder cancer while 10 underwent cystectomy. Among patients with high-grade disease, overall, cancer-specific, and cystectomy-free survivals were 87%, 96%, and 84% at 2 years, respectively. Adverse events included bladder spasms (n = 18), urinary frequency (n = 10), and dysuria (n = 8). Two patients could not tolerate valrubicin and docetaxel induction. CONCLUSIONS: In a heavily pretreated population, our results suggest valrubicin and docetaxel is an effective rescue treatment for patients with recurrent non-muscle-invasive bladder cancer. Further prospective evaluation is needed.

Number of cores needed to diagnose prostate cancer during MRI targeted biopsy decreases after the learning curve.

INTRODUCTION: We hypothesized that the number of cores needed to detect prostate cancer would decrease with increasing MRI-targeted biopsy (TBx) experience. METHODS: All patients undergoing TBx at our institution from May 2017 to August 2019 were enrolled in a prospectively maintained database. Five biopsy cores were obtained from each lesion ≥3 on PI-RADS v2.0 followed by a systematic 12-core biopsy. To assess learning curve, the study population was divided into quartiles by sequential biopsies. Clinically significant prostate cancer (csPC) was defined as Gleason Grade Group 2 or higher. RESULTS: 377 patients underwent prostate biopsy (533 lesions); 233 lesions (44%) were positive for prostate cancer and 173 lesions (32%) were csPC. There was a significant decline in the number of cores required for diagnosing any cancer (P < 0.001) and csPC (P < 0.05) after the first quartile. There was no difference when stratifying by PI-RADS score or lesion volume. Within the first quartile, limiting the biopsy to 3 cores would miss 16.2% of csPC, decreasing to 6.6% after approximately 100 patients. CONCLUSION: MRI TBx is associated with a learning curve of approximately 100 cases. Four or 5 cores should be considered during the initial experience, but thereafter, 3 cores per lesion is sufficient to detect csPC.

Knowledge and Attitudes Regarding Surgical Castration in Men Receiving Androgen Deprivation Therapy for Metastatic Prostate Cancer and Their Relationship to Health-Related Quality of Life.

OBJECTIVE: To determine the attitudes and education regarding surgical castration in men receiving androgen deprivation therapy (ADT) for metastatic prostate cancer (mCaP). METHODS: We identified 142 patients receiving ADT for mCaP at our institution without prior orchiectomy who were then sent 2 surveys via mail: (1) A questionnaire to assess knowledge and understanding of ADT treatment alternatives and (2) the functional assessment of cancer therapy - prostate (FACT-P) questionnaire which determines health-related quality of life (HRQOL). Two cohorts were created based on the answer to "would you be interested in surgical orchiectomy?" and demographic, CaP and HRQOL were compared between the surgical castration yes (SC+) and surgical castration no (SC-) cohorts. A second analysis identified predictors of worse HRQOL. RESULTS: Of 68 (47.9%) patients that responded to the survey, only 39 (59.1%) recalled a discussion regarding treatment alternatives to ADT and only 22 (33.3%) recalled a discussion regarding orchiectomy. There were 24 (40.0%) patients that stated interest in undergoing orchiectomy (SC+) as an alternative to ADT with the only independent risk factor being "…bother from the number of clinical appointments required for ADT…" Patients most bothered by side effects and cosmetic changes associated with ADT reported lower HRQOL scores on the FACT-P. CONCLUSIONS: Few men on ADT knew about surgical alternatives, implying that educational deficits may be a significant factor in the decline in the utilization of orchiectomy. Changes in healthcare economics, utilization and delivery brought on by a global pandemic should warrant a fresh look at the use of surgical castration.

Large para-testicular intra-scrotal malignant peripheral nerve sheath tumor managed with radical penectomy: A case report.

Neurofibromatosis 1 is a relatively rare genetic disease characterized by widespread neurofibromas originating from the peripheral nervous system. Most growths are benign, but some carry a risk of transformation to malignant peripheral nerve sheath tumors. Although these growths can be found anywhere in the body, they are rarely found in the male external genitalia. This report discusses a case of a 25-year-old male patient with neurofibromatosis 1 presenting with a scrotal mass found to have a very large para-testicular intra-scrotal malignant peripheral nerve sheath tumor that required testicle-sparing radical penectomy.

Do patients with a PI-RADS 5 lesion identified on magnetic resonance imaging require systematic biopsy in addition to targeted biopsy?

INTRODUCTION: Magnetic Resonance Imaging (MRI)-targeted prostate biopsy (MRI-TB) improves the detection of prostate cancer. These biopsies typically involve both a 12-core systematic biopsy (SB) and MRI-TB of the lesion. Since the majority of PI-RADS 5 lesions represent clinically significant cancers, the utility of SB in addition to MRI-TB is unclear. We evaluate the utility of SB in the setting of PI-RADS 5 lesions in biopsy naïve and active surveillance patients. METHODS: Patients undergoing MRI-TB+SB with a PI-RADS 5 lesion were retrospectively reviewed in a prospectively collected database. Pathology obtained from the MRI-TB was then compared to that of the SB, and each was reported based on the highest Gleason Grade from the sample. In patients with a prior biopsy, we identified instances in which the MRI-TB+SB resulted in upgraded pathology and further subdivided these patients based on whether the pathology upgrade was a result of the TB or the SB. RESULTS: We identified PI-RADS 5 lesions in 97 patients. All lesions biopsied were found to be prostate cancer, and 86.9% were clinically significant. Gleason Grade from the MRI-TB of the PI-RADS 5 lesions was the same or higher to that of the SB in all but 3 cases (3.1%). Among 59 patients with a prior prostate biopsy, 54 had upgraded pathology from MRI-TB+SB (91.5%). Of these 54 patients, MRI-TB pathology of the PI-RADS 5 lesion was the same or higher to that of the SB in 52 patients (96.3%). In all patients with higher Gleason Grade on SB than MRI-TB, the MRI-TB demonstrated GG3 or higher and SB did not change subsequent clinical management. CONCLUSION: In the presence of a PI-RADS 5 lesion, SB offers minimal additional clinical value and could potentially be omitted when performing MRI-TB.

Optimizing MRI-targeted prostate biopsy: the diagnostic benefit of additional targeted biopsy cores.

INTRODUCTION: The optimal number of biopsy cores to obtain during MRI-targeted prostate biopsy remains ill-defined. This study sought to determine the optimal number of targeted biopsy cores to obtain from a region of interest to maximize detection of clinically significant prostate cancer. MATERIALS AND METHODS: Consecutive patients undergoing MRI-targeted prostate biopsy at a single institution that newly implemented a targeted biopsy pathway from May 2017 to February 2018 were prospectively enrolled. Five biopsy cores were obtained and individually analyzed from each region rated ≥3 on PI-RADS v2.0 to determine the incremental diagnostic benefit of each additional targeted biopsy core. Variables associated with increasing Grade Group from the first to fifth biopsy core were assessed. RESULTS: One hundred and four patients (79% for elevated PSA) were enrolled, 82% of which had a prior biopsy. Men with a PI-RADS >3 lesion were more likely to have pathologic upgrading with additional targeted biopsy cores (OR:4.76; 95% CI:2.34-9.70; P < 0.0001), particularly to Grade Group ≥2 (OR:5.16; 95% CI:2.17-12.29; P = 0.0002), compared to men with PI-RADS 3 lesions. Detection of clinically significant cancer increased from 26% to 44% to 52% when comparing the first, third, and fifth biopsy cores amongst men with a PI-RADS >3 lesion and from 1% to 4% to 9% for PI-RADS 3 lesions. Urinary retention was the most common complication, occurring in 6 (5.7%) patients. CONCLUSION: Clinically significant prostate cancer detection is improved with increased number of MRI-targeted biopsy cores, particularly for urologists early in their learning curve.

Circumcision, Buried Penis and Obesity in a Contemporary Cohort of Patients with Penile Cancer.

INTRODUCTION: We reviewed patient demographics and body morphology in a contemporary cohort of patients presenting to a tertiary care center for treatment of penile cancer. METHODS: The University of Iowa Oncology Registry was retrospectively reviewed for cases of penile cancer managed between 2006 and 2016. The database was queried for cancer specific details, followed by a chart review for body morphology data and comorbidity status. RESULTS: We treated 54 patients for penile cancer in the study period with a mean ± SD age of 64.3 ± 12.9 years and body mass index of 36.2 ± 10 kg/m2. Of these men 31.5% (17) had a clinically buried penis and 50% (27) reported prepubertal circumcision. Patients with a buried penis had a higher body mass index (46.53 ± 10.6 vs 31.48 ± 5.63 kg/m2, p <0.0001) and underwent fewer inguinal lymph node dissections (20% vs 58%, p = 0.05) than patients without a buried penis, but had similar rates of higher stage (2-4) presentation. Stage correlated with penile cancer death. Those with cancer specific mortality had a significantly higher body mass index (41.2 ± 12.4 kg/m2) vs those without penile cancer death (34.6 ± 9.1 kg/m2). CONCLUSIONS: Penile cancer remains relatively rare but contemporary cohorts suggest that circumcision may no longer be protective, especially in the setting of a clinically buried penis that may mimic an intact prepuce. How a buried penis and higher body mass index affect presentation, clinical management, surgical outcomes and disease course deserves further study.

Long-term Health-related Quality of Life Outcomes Following Radical Cystectomy.

OBJECTIVE: To evaluate the long-term (>5 years) health-related quality of life (HRQOL) outcomes following radical cystectomy, comparing Indiana pouch (IP), neobladder (NB), and ileal conduit (IC). MATERIALS AND METHODS: The departmental radical cystectomy database was queried to identify patients who underwent radical cystectomy and urinary diversion for bladder cancer between 1991 and 2009 and had not died. Three hundred patients were identified and sent the validated Bladder Cancer Index instrument. RESULTS: A total of 128 (43%) patients completed the survey. When adjusted for gender, age at surgery, surgeon, and time since surgery, IC and IP patients had significantly better urinary function than NB patients (P = .0013). Sexual bother was less in NB than IP (P = .0387). Among men ≥65 years of age, IC patients had significantly better urinary function (P = .0376) than NB patients (91.6 vs 49.4, respectively). Among men <65 years of age, IC and IP patients (76.0 and 82.8, respectively) had significantly better urinary function than NB patients (50.7) (P = .0199). Among women greater than 65 years, bowel bother was significantly better (P = .0095) for IC patients than IP patients (44.8 vs 69.5, respectively). CONCLUSION: Urinary diversion type after radical cystectomy affects HRQOL differently in long-term survivors. Age and gender at surgery influenced HRQOL based on diversion procedure. Urinary function but not urinary bother was significantly better in IC and IP compared to NB diversions. Prospective longitudinal studies using validated HRQOL tools will further help guide preoperative diversion choice decisions between patient and surgeon.

Neoadjuvant chemotherapy in urothelial bladder cancer: impact of regimen and variant histology.

AIM: We compared the efficacy of methotrexate/vinblastine/doxorubicin/cisplatin (MVAC) versus gemcitabine/cisplatin in urothelial cancer and neoadjuvant chemotherapy (NACT) efficacy in variant histology (VH). MATERIALS & METHODS: Radical cystectomy patients were retrospectively compared with those who received NACT. Factors associated with survival, pathologic complete response (pCR) and downstaging (pDS) were evaluated in multivariable models. RESULTS: 9% of radical cystectomy patients (84/919) received NACT, with improved survival, pCR and pDS on both regimens. MVAC lead to higher pDS without an increase in pCR. On multivariable analysis, there was a nonsignificant increase in pDS with MVAC. NACT conferred similar responses in squamous and glandular differentiation VH. CONCLUSION: NACT was associated with improved survival, pCR and pDS. Furthermore, responses to NACT were not dependent on presence of VH.

Robot-Assisted Radical Prostatectomy in Patients with a History of Holmium Laser Enucleation of the Prostate: Feasibility and Evaluation of Initial Outcomes.

PURPOSE: To evaluate outcomes of post-holmium laser enucleation of the prostate (HoLEP) robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: Using an institutional database, we identified 11 HoLEP patients who subsequently underwent RARP. These were matched 1:2 to RARP patients without a previous transurethral surgical procedure. Variables matched were age, pre-RARP prostate-specific antigen level, and biopsy Gleason score. Urinary continence and sexual function were evaluated by physician questioning, American Urological Association symptom score, and Sexual Health in Men (SHIM) scores. Descriptive statistics were used to compare cohorts. RESULTS: RARP pathologic outcomes were similar between cases and controls. Twenty-seven percent of previous HoLEP patients reached strict urinary continence (leak free, pad free) at last follow-up compared with 64% of matched controls (P=0.071). The average (range) SHIM score at last follow-up was 2.6 (1-5) for previous HoLEP patients compared with 13.9 (5-20) (P<0.001). The posterior bladder neck and apical dissections were significantly more challenging in the setting of previous HoLEP and necessitated a low threshold for wider resection to minimize positive surgical margins. CONCLUSIONS: Post-HoLEP RARP is challenging but preliminarily appears safe and feasible when performed by an experienced robotic surgeon. Patients should be counseled regarding expectations of urinary continence and sexual function in this setting.

Can radiologists and urologists reliably determine renal mass histology using standard preoperative computed tomography imaging?

PURPOSE: To determine the extent to which radiologists and urologists can predict histology using multiphasic CT imaging. METHODS: Patients with a preoperative multiphasic CT undergoing surgery for a renal mass were identified between 2003 and 2013. Tumors >10 cm, locally advanced or metastatic disease, and patients managed by reviewers were excluded. A survey and deidentified scans were provided to reviewers. Sensitivity and accuracy in predicting histology was calculated for each reviewer. Correlation was assessed by the Fleiss kappa coefficient. Multivariable logistic regression determined factors associated with predictive accuracy for final pathology. RESULTS: There were 120 patients who met criteria. Mean tumor size was 3.3 cm; there were 102 (85%) that were malignant, and 73% of these were clear-cell renal-cell carcinoma (RCC). The most common benign histology was angiomyolipoma (n=10, 56%) followed by oncocytoma (n=5, 28%). Correlation among reviewers was statistically fair for predicting malignant (κ=0.25) and final pathology (κ=0.22). Sensitivity for predicting malignant masses was 90%. Reviewers accurately predicted malignant pathology in 82% of cases and predicted final pathology in 58% of cases. Adjusted for size, scan type, and reviewer, clear-cell RCC vs benign histology was associated with 21 times increased odds of accurate pathologic identification (P<0.001). CONCLUSIONS: Urologists and radiologists were able to accurately identify malignant histology in 82% of cases, although sensitivity for malignant histology was 90%. Developing a preoperative nomogram for identification of clear-cell RCC may be feasible and should be further explored.

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

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

R.E.N.A.L. Nephrometry scoring: how well correlated are urologist, radiologist, and collaborator scores?

PURPOSE: R.E.N.A.L. Nephrometry Score (NS) is an imaging-based (CT/MRI) scoring system commonly used by urologists to standardize the reporting of renal masses by enabling quantification of anatomical characteristics. We sought to examine the inter-rater correlation of NS between urologists, radiologists, and tumor-board collaborators. METHODS: We identified adult patients undergoing partial or radical nephrectomy over 10 years (n=2450). Patients with autosomal dominant polycystic kidney disease (ADPKD), metastatic disease, masses >10 cm, and studies in which the study urologists or radiologists partook in patient care were excluded. Preoperative imaging was evaluated and patients with multiphasic CT available were included. Scans were provided to the reviewers to evaluate with a R.E.N.A.L. nephrometry questionnaire. Results were analyzed using kappa correlation coefficients. RESULTS: One hundred twenty patients met inclusion criteria with mean age of 59.5 years. The majority of cases were partial nephrectomies (72%). Eighty-five percent of the tumors were malignant, with 26% having high-grade histology. The mean (standard deviation) overall NS was 6.8 (1.9) with fair correlation among reviewers (κ=0.222). Collaborators had the highest inter-rater correlation, ranging from 0.41 to 0.84 for NS component scores, compared with 0.42-0.85 for radiologists and 0.36-0.86 for urologists. "R" scores were best correlated (κ>0.8). NS correlation ranged between 0.16 and 0.31 for the groups while the NS complexity category correlation ranged between 0.50 and 0.61. CONCLUSIONS: Despite being naive to NS, inter-radiologist scoring patterns were better correlated than inter-urologist. The urologist and radiologist collaborating in tumor board showed the highest agreement, suggesting that a multidisciplinary approach in the characterization of renal masses may provide benefit to patient management.