The Current Application and Future Potential of Artificial Intelligence in Renal Cancer.

Artificial intelligence (AI) is the integration of human tasks into machine processes. The role of AI in kidney cancer evaluation, management, and outcome predictions are constantly evolving. We performed a narrative review utilizing PubMed electronic database to query AI as a method of analysis in kidney cancer research. Key search-words included: Artificial Intelligence, Supervised/Unsupervised Machine Learning, Deep Learning, Natural Language Processing, Neural Networks, radiomics, pathomics, and kidney or renal neoplasms or cancer. 72 clinically relevant and impactful studies related to imaging, histopathology, and outcomes were recognized. We anticipate the incorporation of AI tools into future clinical decision-making for kidney cancer.

Automated Analysis of Split Kidney Function from CT Scans Using Deep Learning and Delta Radiomics.

Background: Differential kidney function assessment is an important part of preoperative evaluation of various urological interventions. It is obtained through dedicated nuclear medical imaging and is not yet implemented through conventional Imaging. Objective: We assess if differential kidney function can be obtained through evaluation of contrast-enhanced computed tomography(CT) using a combination of deep learning and (2D and 3D) radiomic features. Methods: All patients who underwent kidney nuclear scanning at Mayo Clinic sites between 2018-2022 were collected. CT scans of the kidneys were obtained within a 3-month interval before or after the nuclear scans were extracted. Patients who underwent a urological or radiological intervention within this time frame were excluded. A segmentation model was used to segment both kidneys. 2D and 3D radiomics features were extracted and compared between the two kidneys to compute delta radiomics and assess its ability to predict differential kidney function. Performance was reported using receiver operating characteristics, sensitivity, and specificity. Results: Studies from Arizona & Rochester formed our internal dataset (n = 1,159). Studies from Florida were separately processed as an external test set to validate generalizability. We obtained 323 studies from our internal sites and 39 studies from external sites. The best results were obtained by a random forest model trained on 3D delta radiomics features. This model achieved an area under curve (AUC) of 0.85 and 0.81 on internal and external test sets, while specificity and sensitivity were 0.84,0.68 on the internal set, 0.70, and 0.65 on the external set. Conclusion: This proposed automated pipeline can derive important differential kidney function information from contrast-enhanced CT and reduce the need for dedicated nuclear scans for early-stage differential kidney functional assessment. Clinical Impact: We establish a machine learning methodology for assessing differential kidney function from routine CT without the need for expensive and radioactive nuclear medicine scans.

Robotic-assisted Laparoscopic Repair of Kidney Transplant Ureteral Strictures.

OBJECTIVE: To evaluate outcomes of robotic-assisted transplant ureteral repair (RATUR) for the management of kidney transplant ureteral strictures (TUS). METHODS: We retrospectively analyzed 41 consecutive patients who underwent RATUR for TUS at multiple tertiary referral centers between January 2016 and December 2022. RATUR was performed utilizing a robotic-assisted transperitoneal approach. The primary outcome was stricture recurrence rate and secondary outcomes included postoperative complicate rate, determining factors impacting with allograft functional recovery, and rate of conversion to open surgery. Categorical and continuous variables are displayed as total number (Percentage) or median [Interquartile Range], respectively. Pearson correlation coefficient was utilized to assess categorical variable correlation with creatinine. RESULTS: The median age was 56years [44,66]. The female-to-male ratio was 1.1:1. Approximately 66% of patients were dialysis-dependent prior to kidney transplantation. TUS was identified at a median time of 4months [2, 15.5] following kidney transplant. Median stricture length was 2 cm [1.22, 2.9 cm]. There were no TUS recurrences with a median follow-up of 36months [24,48]. There were 3 Clavien grade 2 and 1 Clavien grade 3 complications (9.5%). No baseline characteristics or preoperative diagnostics were correlated with a long-term decline in renal allograft function. CONCLUSION: RATUR has excellent and durable outcomes with low complication rates. These findings encourage the use of a minimally invasive definitive repair as a first-line treatment option for the management of TUS.

Performing Automatic Identification and Staging of Urothelial Carcinoma in Bladder Cancer Patients Using a Hybrid Deep-Machine Learning Approach.

Accurate clinical staging of bladder cancer aids in optimizing the process of clinical decision-making, thereby tailoring the effective treatment and management of patients. While several radiomics approaches have been developed to facilitate the process of clinical diagnosis and staging of bladder cancer using grayscale computed tomography (CT) scans, the performances of these models have been low, with little validation and no clear consensus on specific imaging signatures. We propose a hybrid framework comprising pre-trained deep neural networks for feature extraction, in combination with statistical machine learning techniques for classification, which is capable of performing the following classification tasks: (1) bladder cancer tissue vs. normal tissue, (2) muscle-invasive bladder cancer (MIBC) vs. non-muscle-invasive bladder cancer (NMIBC), and (3) post-treatment changes (PTC) vs. MIBC.

Median lobe vs. complete gland holmium laser enucleation of the prostate: A propensity score matching.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is a common condition affecting aging men. While holmium laser enucleation of the prostate (HoLEP) is one of the most effective treatments for BPH, variations of the procedure, such as median lobe HoLEP (MLHoLEP), are rarely reported. Here, we report our institution's experience with partial HoLEP. METHODS: Our institutional prospective database was queried for patients having undergone median or individual lateral lobe enucleation between 2007 and 2018. A control cohort of patients who underwent standard HoLEP (sHoLEP) was identified using 1:2 propensity score matching based on age, prostate size, maximal flow rate (Qmax), postvoid residual volume (PVR), and American Urological Association symptom score (AUAss). Three and 12-month AUAss, PVR, and Qmax were compared. RESULTS: Forty-seven patients were identified as having undergone MLHoLEP. At three-month followup, AUAss (p<0.01) and incontinence rates (p=0.045) were lower for MLHoLEP patients, in addition to them having shorter operative (36.5 mins vs. 64.5 mins, p<0.01) and enucleation (13.8 mins vs. 37 mins, p<0.01) times as compared to sHoLEP patients. No difference was noted between MLHoLEP and sHoLEP cohorts with respect to age, prostate volume, PVR, or Qmax. Significant improvement in AUAss, PVR, and Q max from baseline to three and 12 months was noted overall in both groups. CONCLUSIONS: MLHoLEP could provide a surgical option with reduced operative time, quicker improvement in AUAss, and restored continence in appropriately selected patients. Ultimately, MLHoLEP represents a safe and effective treatment option to select patients who may not be eligible for or face potential morbidity concerns associated with sHoLEP.

Travel characteristics and outcomes for patients seeking HoLEP.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) is an effective but underutilized option for the surgical management of benign prostatic hyperplasia (BPH). With low adoption, questions arise surrounding patients access to care. It is unclear whether patients undergoing HoLEP are local or specifically seek care from afar. We looked to determine the proportion of patients who traveled out-of-state for HoLEP treatment and the impact of travel on peri and postoperative metrics. MATERIALS AND METHODS: We performed a retrospective cohort study evaluating patients that underwent HoLEP at a single institution from 2007-2019. Patient demographic, perioperative data, postoperative outcomes, travel distance and income data were compared between those who traveled and did not travel out-of-state for care. RESULTS: From 2007-2019, 1565 patients underwent HoLEP at our institution. The mean age was 70.0 years, average body mass index (BMI) of 27.9 kg/m2, and 91.6% identified as Caucasian; 44.2% of patients traveled from out-of-state for HoLEP care, traveling a median of 597 miles. Patients who came from out-of-state had larger prostates (p = 0.005) and worse preoperative International Prostate Symptom Score (IPSS) total and bother scores (p = 0.002). There was no difference in immediate, 30 or 90 day complications rates. In- and out-of-state patients had similar postoperative urinary and functional outcomes. CONCLUSIONS: A large proportion of patients specifically seek out HoLEP and travel out-of-state for care. The reasons are likely multifactorial -including advanced disease, lack of local care and healthcare consumerism. These results have implications both for those currently providing HoLEP as a treatment option as well as those motivated to start a HoLEP practice.

Outcomes and rates of dissolution therapy for uric acid stones.

INTRODUCTION: To describe the outcomes and quantify the rate of uric acid stone medical dissolution therapy using automated, software-generated stone volume measurements. METHODS: A sample of patients treated with oral dissolution therapy was reviewed from a single institution between 2008 and 2019. Baseline patient demographics, metabolic urine testing and stone characteristics were collected. Computed tomography (CT) scan images were evaluated using the quantitative Stone Analysis Software (qSAS) to obtain total stone volume (TSV), maximum diameter (MD) and stone number. Rate of dissolution using total stone volume was calculated over the treatment period. RESULTS: Twenty-seven patients were started on oral dissolution therapy, corrected for renal function. After mean duration of 180 days (range 41-531), 16 patients failed treatment resulting in surgical therapy. Twenty stones in 11 patients showed complete or partial dissolution. Compared to those who failed treatment, patients with complete or partial dissolution had lower 24 h urinary uric acid and higher treatment urine pH. Thirteen (65%) stones showed complete dissolution after a mean 167.6 days. Rate of change for responders was 4.73 mm3 or 0.6% of total stone volume per day. Time to dissolution of one half of stone volume based on total stone volume was 86 days (12.30 weeks). DISCUSSION/CONCLUSIONS: Software-calculated total stone volume may be an effective method of measuring uric acid stone response to oral alkalization therapy. Stone volume decreased by 50% after 12.3 weeks of treatment and could be an important benchmark for oral dissolution therapyoral dissolution therapy. Further studies with a larger sample and validation of the software are needed to confirm if this can be used to guide surveillance schedules for dissolution therapy.

Outcomes of post-chemotherapy robot-assisted retroperitoneal lymph node dissection in testicular cancer: multi-institutional study.

OBJECTIVE: To evaluate the perioperative and oncological outcomes after post-chemotherapy robot-assisted retroperitoneal lymph node dissection (PC-RARPLND). MATERIALS AND METHODS: We retrospectively reported the perioperative and oncological outcomes of all the patients with testicular cancer who underwent PC-RARPLND at three tertiary teaching centers. Descriptive statistical measures were used to report demographic, clinical, intraoperative, postoperative and oncological outcomes. RESULTS: There were 43 consecutive patients who underwent PC-RARPLND at the participating institutions. Mean patient age was 29.2 years (± 8.2), BMI was 26.6 kg/m2 (± 6.2). The mean size of retroperitoneal mass was 4.1 cm (± 3.5). Full bilateral template dissection was performed in 38 (88.3%) patients. Nerve sparing was attempted in 19 (44.1%) patients. Mean operative time was 374 min (± 132) and estimated blood loss was 292 ml (± 445.6). The mean postoperative LOS was 2.8 days (± 5.9). There was a total of 12 complications in 10 patients (Clavien grade I = 5, II = 3, III = 3 and IV = 1). Postoperative pathology demonstrated 24 patients (55%) with necrosis/fibrosis, 16 (37%) with teratoma and 3 (7%) with viable tumor. Mean lymph node (LN) yield was 26.5 LNs (SD ± 16.1). Patients were followed for a mean of 30.7 months (± 24.7). No deaths were documented during follow-up and 2 pulmonary recurrences were identified. Antegrade ejaculation was preserved in 70.6% of patient who underwent nerve sparing. Limitations included retrospective nature and limited follow up. CONCLUSION: PC-RAPLND is safe and technically reproducible. It provides improved morbidity and less convalescence.

Learning Curve for Robotic-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection.

Introduction: Robotic retroperitoneal lymph node dissection (R-RPLND) is a challenging procedure. We hypothesized that surgical times and operative complications would decrease as surgeons became more facile with R-RPLND. Materials and Methods: We retrospectively reviewed 121 consecutive R-RPLNDs performed at Naval Medical Center San Diego and Mayo Clinic Arizona by 4 fellowship trained robotic surgeons between 2008 and 2018. Linear regression was used to analyze independent predictors of setup time, operative time, and lymph node counts. Logistic regression was used to analyze open conversions, overall complications, and high-grade complications. Variables included as independent predictors were: sequential case number, surgeon, clinical stage, chemotherapy status, RPLND template, and body mass index. Univariate and multivariate analyses were conducted. Statistical significance was established at α = 0.05. Results: There was no change in setup time with case number (p = 0.317), but differences were noted between surgeons. Operative times decreased with increasing case number (p < 0.001) but were negatively affected by clinical stage III testis cancer (p = 0.029) and history of chemotherapy exposure (p = 0.050). Surgical times are predicted to decrease by 1 hour after 44 cases. Lymph node counts were dependent only on the surgeon. No factors were predictive of open conversions. Fewer overall complications occurred as experience was gained (p = 0.001), but high-grade complications could not be predicted. Conclusions: Consistent with the learning curves shown for other technologically advanced surgical techniques, experience appears to improve surgical times and lower complication rates for R-RPLND.

Effect of intracorporeal urinary diversion on the incidence of benign ureteroenteric stricture after cystectomy.

OBJECTIVES: To compare ureteroenteric stricture rates after radical cystectomy in patients who undergo an intracorporeal urinary diversion versus other surgical approaches. METHODS: We retrospectively reviewed health records of all patients who underwent cystectomy with urinary diversion at Mayo Clinic Hospital (Phoenix, AZ, USA) from 1 January 2007 through 1 January 2018. Ureteroenteric stricture was identified by surveillance imaging. Patients were stratified by surgical approach: open radical cystectomy, robot-assisted radical cystectomy with extracorporeal urinary diversion and robot-assisted radical cystectomy-intracorporeal urinary diversion. A Cox proportional hazards model was fitted that included independent predictors of stricture development. RESULTS: Of the 573 cystectomies assessed, 236 (41.2%) were carried out robotically. In the robot-assisted radical cystectomy cohort, 39 patients (16.5%) underwent intracorporeal urinary diversion. The median follow-up period was 55, 70 and 71 months for the open radical cystectomy, robot-assisted radical cystectomy-extracorporeal urinary diversion and robot-assisted radical cystectomy-intracorporeal urinary diversion groups, respectively. Subgroup stricture rates were as follows: open radical cystectomy, 8.0%; robot-assisted radical cystectomy-extracorporeal urinary diversion, 9.6%; and robot-assisted radical cystectomy-intracorporeal urinary diversion, 2.6% (P = 0.33). The median time to stricture was 5 months (interquartile range 3.3-11.5 months). In the bivariable analysis, factors that were associated with the development of ureteroenteric stricture were postoperative urinary leak (hazard ratio 3.177, 95% confidence interval 1.129-8.935; P = 0.03) and body mass index (hazard ratio 1.078, 95% confidence interval 1.027-1.132; P = 0.002). On multivariable logistic regression analysis, intracorporeal urinary diversion approach was not associated with the development of ureteroenteric stricture (hazard ratio 0.272, 95% confidence interval 0.036-2.066; P = 0.21). CONCLUSIONS: Ureteroenteric stricture is a complication that typically occurs within the first postoperative year. Although our results did not support major differences in outcomes between intracorporeal urinary diversion and extracorporeal urinary diversion, the small sample size did not exclude the possibility of a type 2 statistical error.

Holmium laser enucleation of the prostate for very large benign prostatic hyperplasia (≥ 200 cc).

PURPOSE: Patients presenting with prostate gland sizes greater than 200 cc pose a unique surgical challenge to both patients and surgeons. The objective of this study is to critically assess the efficacy and risks associated with performing holmium laser enucleation of the prostate (HoLEP) on glands ≥ 200 cc. MATERIALS AND METHODS: Using a prospective maintained database, all consecutive benign prostatic hyperplasia (BPH) patients with gland size ≥ 200 cc who underwent HoLEP were included. We reported patient preoperative, intraoperative, postoperative outcomes and complications. Subgroup analysis of outcomes was stratified by gland sizes 200-299 cc and ≥ 300 cc. Univariate analysis using Kruskal-Wallis and Fisher exact test was performed to compare the two groups. RESULTS: There were 88 patients with a mean preoperative gland size of 255.9 cc (200-770 cc). Mean operative (171 vs 182 min) and enucleation time (77 vs 83 min) were not different between the two subgroups (200-299 cc vs ≥ 300 cc). Enucleation efficiency was greater for glands ≥ 300 cc (2.6 cc/min vs 2.0 cc/min, p = 0.04). Morcellation time was longer in the ≥ 300 cc group (74.5 min vs 46.8 min, p = 0.021). Mean length of stay was 1.8 ± 1.2 days and catheter duration was 2.6 ± 2.7 days. 1 (1.1%) patient required retreatment of BPH at last follow-up. The main limitation of this study is the retrospective data analysis. CONCLUSIONS: Holmium laser enucleation for prostate glands volume > 200 cc is feasible with minimal morbidity. These data further reinforce the size independence success of this procedure for BPH.

Outcome prediction following radical nephroureterectomy for upper tract urothelial carcinoma.

OBJECTIVE: To predict overall survival, cancer, and metastasis specific survival in upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy (RNU). MATERIALS AND METHODS: All nonmetastatic UTUC patients who underwent RNU with a curative intent at 1 institution between December 1998 and January 2017 were included.  Detailed data were collected. End points for this study included OS, CCS, and MFS. Univariate and multivariate analysis were conducted. Log Rank tests and Kaplan-Meier curves were generated. Backward elimination and boot strapping was used to identify the most parsimonious model with the smallest number of variables in order to predict the outcomes of interest. A separate second institution data base was used for external validation. RESULTS: There were 218 patients in the development cohort. Mean follow-up was 42 months (±39.6). There was 99 (45.4%) deaths, 28 (12.8%) cancer related deaths, 72 (33%) recurrences, and 54 (24.8%) metastases. The c-index for our model was 0.71 for OS, 0.72 for MFS and 0.74 for CSS. The nomograms did not show significant deviation from actual observations using our calibration plots. We divided the patient into 3 different groups (low, intermediate and high risk) based on their final total score for each outcome and compared them. On external validation our accuracy was 78.4%, 71.4%, and 75.3% for OS, CSS, and MFS survival respectively. CONCLUSION: We designed a predictive model for survival outcomes following RNU in UTUC. This model uses simple, readily available data for patients without the need for expensive or additional testing.

Robot Assisted Renal Allograft Nephrectomy: Initial Case Series and Description of Technique.

OBJECTIVE: To evaluate the outcomes and perioperative complication rates following robot- assisted transplant nephrectomy ((RATN). METHODS: All patients who underwent RATN at our institution were included. No exclusion criteria were applied. Clinical records were retrospectively reviewed and reported. This included preoperative, intraoperative, and postoperative outcomes. Complications were reported utilizing the Clavien-Dindo classification system. Descriptive statistics were reported using frequencies and percentages for categorical variables, means and standard deviation for continuous variables. RESULTS: Between July 2014 and April 2018, 15 patients underwent RATN. Most patients had the transplant in the right iliac fossa (13/15). Ten patients underwent a concomitant procedure. The total operative time for the entire cohort was 336 (±102) minutes (including cases who had concomitant procedures) and 259 (±46 minutes) when cases with concomitant procedures were excluded. Mean estimated blood loss was 383 (±444) mL. Postoperatively, 3 patients required blood transfusion. Average hospital stay was 4 (±2.7) days. Most patients had finding consistent with graft rejection on final pathology. There were 5 complications; 3 of which were minor (grade 2 = 2 and grade 3 = 1); one patient had a wound infection requiring dressing (3A) and one patient died due to pulmonary embolism following discharge. Limitations include small series and retrospective nature of the study. CONCLUSION: This case series demonstrate that RATN is technically feasible. With continued experience and larger case series, the robotic approach may provide a minimally invasive alternative to open allograft nephrectomy.

Assessment of Polyethylene Glycol Hydrogel Spacer and Its Effect on Rectal Radiation Dose in Prostate Cancer Patients Receiving Proton Beam Radiation Therapy.

PURPOSE: To assess the efficacy of placing a polyethylene glycol (PEG) spacing hydrogel in patients undergoing proton beam radiation therapy for prostate cancer. This study also aims to assess the effect on rectal radiation dose of prostate-rectum separation in various anatomic planes. METHODS AND MATERIALS: Seventy-two consecutive prostate cancer patients undergoing conventionally fractionated pencil beam scanning proton radiation therapy with and without hydrogel placement were compared. Magnetic resonance images taken after hydrogel placement measured prostate-rectum separation and were correlated to rectal dosing and rectal toxicity. Univariate analysis of clinical variables and radiation dosing was conducted using nonparametric Wilcoxon rank-sum test with continuity correction between groups (hydrogel spacer vs controls). Spearman's rank correlation coefficient assessed relationships between the various anatomic dimensions of perirectal space and rectal radiation dosing. RESULTS: Fifty-one patients had hydrogel placement before therapy and 21 did not. There was a 42.2% reduction in rectal dosing (mL3 rectum) in hydrogel patients (P < .001). Increasing midline sagittal lift resulted in a greater mitigation of total rectal dose (P = .031). The degree of prostate surface area coverage on coronal plane did not correlate with further reductions in rectal radiation dose (P = .673). Patients who had PEG hydrogels placed reported more rectal side effects during treatment compared with those patients who did not (35.3% vs 9.5%, P = .061). At median 9.5-month follow-up, there was no difference in reporting of grade ≤2 rectal toxicity between the 2 groups (7.7% vs 7.1%, P = .145). CONCLUSIONS: Polyethylene glycol hydrogel placement before pencil proton beam radiation therapy for prostate cancer reduced rectal radiation dose. The most important factor reducing total rectal dose was the degree of sagittal midline separation created by the PEG hydrogel. This is the largest study with the longest follow-up to investigate hydrogel placement in the proton beam radiation setting.

Incidence, Outcomes, and Prediction of Postoperative Urinary Retention After a Nonurologic Procedure.

PURPOSE: To develop a prognostic model to estimate postoperative urinary retention (POUR) after lower limb arthroplasty. METHODS: One thousand two hundred twenty patients underwent 1,374 joint replacement operations (812 knees and 562 hips) between December 2008 and May 2014. Detailed variables were collected. A multivariable logistic regression model was used to identify the independent predictors for POUR. Boot strapping and stepwise elimination was used to design a predictive nomogram. RESULTS: There were 124 incidents of POUR (9.02%) in 118 patients (90 knee, 34 hip, P = 0.001). On univariate analysis, patients who developed POUR were older (P < 0.001), had higher American Association of Anesthesiology scores (P = 0.007), underwent knee replacement (0.001), were obese (body mass index > 35) (P = 0.04), and were hypertensive (P = 0.029), with a history of benign prostatic hyperplasis (BPH) (P < 0.001) or neurologic disorders (P = 0.024). On multivariable analysis, age (60 to 69 years, P = 0.023, 70 to 79 yrs P = 0.008, >80 years P = 0.003), knee replacement (P = 0.014), and history of BPH (P = 0.013) were the independent predictors of POUR. A score was assigned to each predictor (total = 31). The C-index was 0.65. There were three risk categories as follows: 0 to 50, 51 to 85, and 86+ points resulting in 3.3%, 7.2%, and 14.0% risk of retention, respectively. DISCUSSION: This nomogram reliably predicts the risk of POUR in patients undergoing hip and knee arthroplasties and may help planning preoperative interventions to decrease the risk of this complication.

Feasibility of holmium laser enucleation of the prostate as a 1-day surgery.

PURPOSE: To assess the safety and feasibility of HoLEP as a day-case procedure. METHODS: We reviewed all consecutive patients who underwent HoLEP at our institution between February 2017 and March 2018. During this time, we began a prospective trial aimed at same-day discharge of specific patients. Baseline and demographic variables, and past medical, past urological, intra-operative and post-operative variables in addition to disposition and readmission data were collected. Bivariate analysis was conducted to compare patients based on the day of discharge and readmission. A multivariable model using multiple-regression analysis was used to assess predictors for early discharge or readmission. RESULTS: There were 179 total HoLEP procedures that were performed during the study period. Forty-seven patients were suitable candidates for same-day discharge. Among this group, 28 (59.5%) patients were successfully discharged home on the same day. Nineteen patients (40.4%) could not be discharged. The most common cause of not to discharge patients was the degree of hematuria without continuous bladder irrigation. Pre-operative prostate volume was different between the two groups (88.4 ± 30.7 cc for discharged patients vs 69.0 ± 30.7 cc for admitted patients, p = 0.033). No other pre-operative differences were identified. There were five readmissions (17.8%) following same-day discharge. Readmitted patients had higher rates of history of urinary tract infection (80% vs 26.2%, p = 0.0304). On multivariable analysis, no statistically significant predictors were identified for early discharge or readmission. CONCLUSIONS: Same-day discharge following HoLEP is safe and feasible in well-selected patients.

Primary robotic RLPND for nonseminomatous germ cell testicular cancer: a two-center analysis of intermediate oncologic and safety outcomes.

OBJECTIVE: To evaluate the intermediate-term oncologic outcomes and safety profile of the largest case series of primary robotic retroperitoneal lymphadenectomy for low-clinical-stage non-seminomatous germ cell testicular cancer. METHODS: This was a two-center retrospective analysis of robotic RPLND cases for low-clinical-stage (stage I-IIB) non-seminomatous germ cell testicular cancer in the primary setting. Demographic, perioperative, operative and oncologic variables were collected between March 2008 and May 2019. Descriptive analyses were performed and presented as medians with interquartile ranges for continuous variables and frequency and proportions for categorical variables. A survival analysis of time to recurrence was performed using Cox proportional hazards model. Using logistic regression, risk factors for complications were analyzed. Both univariate and multivariate analyses were performed. RESULTS: A total of 58 patients (CS 1 = 56, CS IIA = 2, CS IIB = 0) were identified. The median follow-up was 47 months and the 2-year recurrence-free survival rate was 91%. The five recurrences were all out of the performed dissection template (pelvis = 1 and lung = 4). Only five patients (29%) with occult metastasis underwent adjuvant chemotherapy. The median operative time was 319 min [interquartile range (IQR) 276-355 min], estimated blood loss was 100 ml (IQR 75-200 ml), node count was 26 (IQR 20-31), and length of stay 2 d (IQR 1-3 days). There were 2 (3.3%) intraoperative complications, 19 (32.7%) 30-day postoperative complications to include 14 (24.1%) Clavien grade I, 4 (6.9%) Clavien grade II, 1 (1.7%) Clavien grade III and 0 Clavien grade IV complications. No statistical significance was found on multivariate or univariate analysis for survival analysis of time to recurrence and risk factors for complications. CONCLUSIONS: This study represents the largest case series of primary R-RPLND for the treatment of low-stage non-seminomatous germ cell tumors (NSGCT). With 47 months of follow-up and a low rate of adjuvant chemotherapy, intermediate oncologic efficacy appears to be comparable to the gold standard open approach.

Comparison of Open and Robot Assisted Radical Nephrectomy With Level I and II Inferior Vena Cava Tumor Thrombus: The Mayo Clinic Experience.

OBJECTIVE: To compare the perioperative and oncologic outcomes associated with open radical nephrectomy with tumor thrombus (O-RNTT) vs robot assisted radical nephrectomy with tumor thrombus (RA-RNTT). Renal cell carcinoma with venous tumor thrombus has traditionally been managed through an open surgical approach. The robot assisted approach may offers improved perioperative outcomes compared to open, but there are few studies comparing these 2. METHODS: We analyzed patients with renal cell carcinoma and inferior vena cava tumor thrombus between 1998 and 2018, comparing perioperative and oncologic outcomes of these patients with Level I and Level II thrombus. Cohorts were stratified by surgical approach: O-RNTT vs RA-RNTT. Univariate analysis was conducted using chi-squared test and t tests when appropriate. Kaplan-Meier estimates were used to evaluate survival. RESULTS AND LIMITATION: Twenty-seven patients were in the O-RNTT group, and 24 in the RA-RNTT group. Patients in the RA-RNTT group, compared to the O-RNTT group, demonstrated shorter length of stay (3 vs 7 nights, P = .03), lower estimate blood loss (450 vs 1800 mL, P <.01), and lower transfusion rate (21% vs 82%, P <.01). The RA-RNTT group had 26% fever complications compared to the open (17% vs 43%, P <.01). There was no significant difference in estimated overall survival or recurrence-free survival between the O-RNTT and RA-RNTT groups. CONCLUSION: RA-RNTT produced a shorter length of stay, less transfusions, and a lower rate of complications with no significant difference in overall survival.

Robot Assisted Surgery of the Vena Cava: Perioperative Outcomes, Technique, and Lessons Learned at The Mayo Clinic.

Introduction: This study aims to describe robot assisted surgery of the inferior vena cava (IVC) by assessing techniques utilized, perioperative outcomes, complications, and long-term patency of the IVC. Methods: A retrospective review was performed on all robotic surgeries involving dissection and repair of the IVC at our institution. Patient characteristics, operative reports, and follow-up visits were analyzed. Preoperative and postoperative imaging was independently reviewed by a single radiologist to determine changes in IVC diameter. Complications were analyzed according to early (<30 days) vs late (>30 days). Results: Thirty-four patients underwent robot assisted surgery of the vena cava from 2008 to 2018. Twenty-six cases were performed for urologic malignancy, four were performed for IVC filter explantation, and four renal vein transpositions were performed for nutcracker syndrome. Twenty-four of the 26 patients with urologic malignancy underwent radical nephrectomy with IVC tumor thrombectomy. Three cases were converted to open. Median length of stay was two nights, and mean estimated blood loss (EBL) was 375 mL. There were five complications, ranging from Clavien-Dindo grade II-IIIa, four of which were early complications. No patients required return to the operating room, and there were no perioperative mortalities. IVC diameter was reduced by 41% on axial diameter, with no patients experiencing compromised venous return. Conclusion: Robot assisted surgery offers the advantage of minimally invasive surgery with the ability to apply open surgical principles. In our series, an experienced multidisciplinary team approach yielded low EBL, short length of stay, and low complication rates.

Robot Assisted Radical Cystectomy vs Open Radical Cystectomy: Over 10 years of the Mayo Clinic Experience.

OBJECTIVES: There is scant information about intermediate / long-term comparative outcomes between robot assisted radical cystectomy (RARC) and open radical cystectomy (ORC). The purpose of this study is to present survival and oncological outcomes between bladder cancer patients who undergo RARC vs. ORC with an overall median follow-up of over 5 years. MATERIALS AND METHODS: A query of all patients who underwent radical cystectomy between January, 2007 and January, 2018 at Mayo Clinic Arizona yielded 595 patients. After excluding cystectomy performed for nonmalignant indication, cancer secondary to nonbladder primary, and cancers with grossly metastatic disease at the time of surgery, 481 patients remained. Data was collected on patient demographics, preoperative information, operative details, complications, and follow-up. Statistical analyses were generated using SPSS 22.0. RESULTS: In 481 total patients, 203 (42.2%) underwent RARC and 278 (57.8%) underwent ORC. The median follow-up for the entire cohort was 66 months. The 5-year recurrence-free survival (RFS) was 70.8% vs. 64.7% and the 10-year RFS was 69.6% vs. 62.7% for the RARC vs. ORC, respectively (P = 0.135). The 5-year overall survival (OS) was 58.9% vs. 57.7% and the 10-year OS was 39.9% vs. 45.6% for RARC vs. ORC patients, respectively (P = 0.466). There were no differences in any recurrence patterns, including the incidence of atypical recurrences (1.5% vs. 1.8% [P = 0.786], respectively). A Cox-proportional hazards model was fitted that included independent predictors of RFS and OS. The results revealed no difference in RFS (HR 1.235, 95% CI: 0.832-1.833, P = 0.295) or OS (HR 0.790, 95% CI: 0.550-1.135, P = 0.202) between the respectively. CONCLUSIONS: Recurrence free survival, OS, and recurrence patterns are similar in bladder cancer patients who undergo either RARC or ORC.