Robot-Assisted Repair of Bladder Rupture following Penile Ring Entrapment.

Penile rings have been used to help sustain erection and enhance sexual pleasure for centuries. Constriction of the penis reduces the outflow of blood from the cavernosal tissue. However, if left for an extended time period, a condition called penile ring entrapment can occur. This may result in severe edema, gangrene, necrosis, and even penile amputation. Penile ring entrapment is a very rare condition; complete urinary obstruction with concomitant bladder rupture as a result renders this case even more extraordinary. We discuss our experience in the management of a 64-year-old man, who presented with altered mental status and inability to urinate, found to have penile ring entrapment and intraperitoneal bladder rupture. Removal of the constricting ring was performed in the ED, and bladder injury and penile necrosis were subsequently repaired with robot-assisted laparoscopic cystorrhaphy, penectomy, and perineal urethrostomy.

Role of the androgen, estrogen, and progesterone receptors in adherent perinephric fat in robotic partial nephrectomy.

To determine whether androgen, estrogen, and/or progesterone signaling play a role in the pathophysiology of adherent perinephric fat (APF). We prospectively recruited patients undergoing robotic assisted partial nephrectomy during 2015-2017. The operating surgeon documented the presence or absence of APF. For those with clear cell renal cell carcinoma (ccRCC), representative sections of tumor and perinephric fat were immunohistochemically stained with monoclonal antibody to estrogen α, progesterone, and androgen receptors. Patient characteristics, operative data, and hormone receptor presence were compared between those with and without APF. Of 51 patients total, 18 (35.3%) and 33 (64.7%) patients did and did not have APF, respectively. APF was associated with history of diabetes mellitus (61.1% vs 24.2%, p = 0.009) and larger tumors (4.0 cm vs 3.0 cm, p = 0.017) but not with age, gender, BMI, Charleston comorbidity index, smoking, or preoperative estimated glomerular filtration rate. APF was not significantly associated with length of operation, positive margins, or 30-day postoperative complications but incurred higher estimated blood loss (236.5 mL vs 209.2 mL, p = 0.049). Thirty-two had ccRCC and completed hormone receptor staining. The majority of tumors and perinephric fat were negative for estrogen and progesterone while positive for androgen receptor expression. There was no difference in hormone receptor expression in either tumor or perinephric fat when classified by presence or absence of APF (p > 0.05). APF is more commonly present in patients with diabetes or larger tumors but was not associated with differential sex hormone receptor expression in ccRCC.

Safety of retrograde pyelography for infected ureteral stones.

INTRODUCTION: Initial management of obstructing ureteral stones with concomitant urinary tract infection (UTI) includes prompt renal decompression and antibiotics. Some urologists theorize that performing retrograde pyelography (RGP) at the time of ureteral stent placement may cause pyelovenous backflow of bacteria thereby worsening clinical outcomes. We compared outcomes in patients with infected ureteral stones who underwent RGP versus no RGP prior to stent placement. MATERIALS AND METHODS: A retrospective chart review was conducted involving patients who presented between 2015 and 2017 with an obstructing ureteral stone and associated UTI. Computed tomography scans were evaluated for stone size and location. Operative reports were reviewed to determine whether the patient underwent RGP at time of ureteral stent placement. Demographics, perioperative information, intensive care unit (ICU) admission rate, and length of stay (LOS) were compared. RESULTS: Seventy-two patients were identified and stratified by severity of condition at presentation, including UTI without sepsis (n = 18), sepsis (n = 32), severe sepsis (n = 11), and septic shock (n = 11). Forty-three patients underwent RGP at the time of stent placement, and 29 did not. Between both patient cohorts, statistical analysis revealed no significant difference in postoperative ICU admission rate (p = 0.35) or LOS for patients with UTI without sepsis (p = 0.17), sepsis (p = 0.45), severe sepsis (p = 0.66), and septic shock (p = 0.25). CONCLUSION: The use of RGP prior to ureteral stent placement for an obstructing ureteral stone with concomitant UTI was not associated with unfavorable clinical outcomes in our retrospective series. While these findings support the safety of RGP in this setting, prospective trials are warranted.

Comparing Off-clamp and On-clamp Robot-assisted Partial Nephrectomy: A Prospective Randomized Trial.

OBJECTIVE: To determine whether performing robot-assisted partial nephrectomy without warm ischemia "off-clamp" results in favorable postoperative renal functional outcomes compared with the on-clamp method. METHODS: We conducted a prospective trial of 80 patients who underwent robot-assisted partial nephrectomy. They were randomized in a 1:1 ratio to undergo the procedure with renal artery clamping or without clamping. The groups were compared across demographics, operative information, perioperative outcomes, and postoperative renal function. We assessed renal function by estimated glomerular filtration rate and renal scintigraphy both preoperatively and at 3 months postoperatively. RESULTS: Patients in the on-clamp and off-clamp groups were similar in age, gender, body mass index, comorbidities, clinical tumor size, nephrometry score, and laterality. Off-clamp procedures were lengthier at an average 178.0 minutes vs 156.0 minutes for on-clamp (P = .011). Estimated blood loss, rates of pelvicalyceal repair, postoperative complications, and positive margins were not different. At a median 3-month follow-up, no significant differences were seen in change in postoperative estimated glomerular filtration rate or percent split renal function between both groups. CONCLUSION: In this prospective study, off-clamp robot-assisted partial nephrectomy resulted in similar perioperative outcomes compared with the on-clamp technique. No benefit was demonstrated in the preservation of renal function. Urologists may safely employ either an on-clamp or off-clamp strategy depending on surgeon preference and patient-specific factors including baseline renal insufficiency, multiple masses, or solitary kidney.

Development and Validity of a Silicone Renal Tumor Model for Robotic Partial Nephrectomy Training.

OBJECTIVE: To provide a training tool to address the technical challenges of robot-assisted laparoscopic partial nephrectomy, we created silicone renal tumor models using 3-dimensional printed molds of a patient's kidney with a mass. In this study, we assessed the face, content, and construct validity of these models. MATERIALS AND METHODS: Surgeons of different training levels completed 4 simulations on silicone renal tumor models. Participants were surveyed on the usefulness and realism of the model as a training tool. Performance was measured using operation-specific metrics, self-reported operative demands (NASA Task Load Index [NASA TLX]), and blinded expert assessment (Global Evaluative Assessment of Robotic Surgeons [GEARS]). RESULTS: Twenty-four participants included attending urologists, endourology fellows, urology residents, and medical students. Post-training surveys of expert participants yielded mean results of 79.2 on the realism of the model's overall feel and 90.2 on the model's overall usefulness for training. Renal artery clamp times and GEARS scores were significantly better in surgeons further in training (P ≤.005 and P ≤.025). Renal artery clamp times, preserved renal parenchyma, positive margins, NASA TLX, and GEARS scores were all found to improve across trials (P <.001, P = .025, P = .024, P ≤.020, and P ≤.006, respectively). CONCLUSION: Face, content, and construct validity were demonstrated in the use of a silicone renal tumor model in a cohort of surgeons of different training levels. Expert participants deemed the model useful and realistic. Surgeons of higher training levels performed better than less experienced surgeons in various study metrics, and improvements within individuals were observed over sequential trials. Future studies should aim to assess model predictive validity, namely, the association between model performance improvements and improvements in live surgery.

Off-clamp robot-assisted partial nephrectomy does not benefit short-term renal function: a matched cohort analysis.

In the interest of renal functional preservation, partial nephrectomy has supplanted radical nephrectomy as the preferred treatment for T1 renal masses. This procedure usually involves the induction of renal warm ischemia by clamping the hilar vessels prior to tumor excision. Performing robot-assisted partial nephrectomy (RAPN) "off-clamp" can theoretically prevent renal functional loss associated with warm ischemia. We describe our institutional experience and compare perioperative and renal functional outcomes using a propensity score matched cohort. We conducted a retrospective comparison from a prospectively maintained database of all patients who underwent RAPN from 2009 to 2015. Of those patients, 143 underwent off-clamp RAPN. Fifty off-clamp RAPN patients were propensity score matched with fifty clamped RAPN patients based on renal function, tumor size, and R.E.N.A.L. nephrometry score. The cohorts were compared across demographics, operative information, perioperative outcomes, and renal functional outcomes. For all off-clamp RAPN patients, mean nephrometry score was 7.1, mean estimated blood loss (EBL) was 236.9 mL, perioperative complication rate was 7.7%, and mean decrease in estimated glomerular filtration rate (eGFR) was 7.1% at a median follow-up of 9.2 months. In the propensity score matched cohorts, off-clamp RAPN resulted in a shorter mean operative time (172.0 versus 196.0 min, p = 0.025) and a lower mean EBL (179.7 versus 283.2 mL, p = 0.046). A lower complication rate of 6.0% in the off-clamp group compared with 20.0% in the clamped group approached significance (p = 0.071). Mean preoperative eGFR was similar in both cohorts. Importantly, there was no significant difference in decrease in eGFR between the clamped cohort (9.8%) and off-clamp cohort (11.9%) at a median follow-up of 9.0 months (p = 0.620). Off-clamp RAPN did not result in improved renal functional preservation in our experience. Surprisingly, the off-clamp cohort experienced lower intraoperative blood loss, shorter operative times, and fewer complications.

Retroperitoneal access for robotic renal surgery.

INTRODUCTION AND OBJECTIVE: Retroperitoneal access for robotic renal surgery is an effective alternative to the commonly used transperitoneal approach. We describe our contemporary experience and technique for attaining retroperitoneal access. MATERIALS AND METHODS: We outline our institutional approach to retroperitoneal access for the instruction of urologists at the beginning of the learning curve. The patient is placed in the lateral decubitus position. The first incision is made just inferior to the tip of the twelfth rib as described by Hsu, et al. After the lumbodorsal fascia is traversed, the retroperitoneal space is dilated with a round 10 millimeter AutoSutureTM (Covidien, Mansfield, MA) balloon access device. The following trocars are used: A 130 millimeter KiiR balloon trocar (Applied Medical, Rancho Santa Margarita, CA), three robotic, and one assistant. Key landmarks for the access and dissection are detailed. RESULTS: 177 patients underwent a retroperitoneal robotic procedure from 2007 to 2015. Procedures performed include 158 partial nephrectomies, 16 pyeloplasties, and three radical nephrectomies. The robotic fourth arm was utilized in all cases. When compared with the transperitoneal approach, the retroperitoneal approach was associated with shorter operative times and decreased length of stay (1). Selection bias and surgeon preference accounted for the higher proportion of patients who underwent partial nephrectomy off-camp via the retroperitoneal approach. CONCLUSIONS: Retroperitoneal robotic surgery may confer several advantages. In patients with previous abdominal surgery or intra-abdominal conditions, the retroperitoneum can be safely accessed while avoiding intraperitoneal injuries. The retroperitoneum also provides a confined space that may minimize the sequelae of potential complications including urine leak. Moreover, at our institution, retroperitoneal robotic surgery is associated with shorter operative times and a decreased length of stay when compared with the transperitoneal approach (2). In selected patients, the retroperitoneal approach is a viable alternative to the transperitoneal approach for a variety of renal procedures.

Trends in the Management of Small Renal Masses: A Survey of Members of the Endourological Society.

Treatment modalities for small renal masses (SRMs) include open or minimally invasive radical or partial nephrectomy, and laparoscopic or percutaneous ablations. Members of the Endourological Society were surveyed to evaluate how practitioner and clinical practice characteristics may be associated with the management of SRMs over time. The survey assessed characteristics of urologists (recency of residency and fellowship training, clinical practice type and location, and treatment modalities available) and their management of SRMs over the past year and over the course of the year 5 years prior. Of the 1495 surveys e-mailed, there were 129 respondents (8.6%). Comparing the past year to 5 years prior, there was increasing utilization of robotic partial nephrectomy (p < 0.001) and robotic radial nephrectomy (p = 0.031). In contrast, there was decreasing utilization of open partial nephrectomy (p < 0.001), open radical nephrectomy (p = 0.039), laparoscopic partial nephrectomy (p = 0.002), and laparoscopic radical nephrectomy (p = 0.041). Employment of laparoscopic ablation decreased (p = 0.001), but that of percutaneous ablation did not change significantly. For masses treated with image-guided therapy, there was increasing utilization of microwave ablation (p = 0.008) and decreasing usage of radiofrequency ablation (p = 0.002). Future studies should focus on the most effective treatment modalities based on provider, patient, and tumor characteristics.

Diagnostic Utility of Selective Upper Tract Urinary Cytology: A Systematic Review and Meta-analysis of the Literature.

The diagnosis of upper tract urothelial carcinoma (UTUC) can be a challenging diagnostic pursuit. To date, there is no large-scale study assessing the statistical utility (eg, sensitivity and specificity) of selective cytology. Herein, we systematically reviewed and meta-analyzed the published literature to evaluate the efficacy of selective cytology for the detection of UTUC in patients with a suspicious clinical profile Selective cytology confers a high specificity but marginal sensitivity for the detection of UTUC. The sensitivity is greater for high-grade UTUC lesions. The statistical assessment of its utility is limited by the heterogeneity and bias of previous studies.

Patient comorbidity predicts hospital length of stay after robot-assisted prostatectomy.

We sought to examine the impact of baseline patient characteristics and perioperative outcomes on postoperative hospital length of stay (LOS), following the robot-assisted radical prostatectomy (RARP). We retrospectively reviewed consecutive patients receiving RARP at our institution by two surgeons between January 2012 and March 2014 (n = 274). Baseline patient characteristics were collected, including Charlson comorbidity index (CCI). Discharge criteria were identical for all patients and included: return of bowel function, pain controlled with oral medications, and ambulation without assistance. LOS was calculated as the number of midnights spent in the hospital following surgery. Postoperative hospital LOS was equal to 1 day for 225 patients and >1 day for 49 patients. Baseline patient and tumor characteristics, including age, race, body-mass index (BMI), pathologic stage, and Gleason score, were not significantly different. Mean operative time was shorter for patients with LOS > 1 day (155 vs. 173 min, p < 0.01) on univariate analysis. Patients with LOS > 1 day were more likely to have had a complication: 8/49 (17 %) vs. 14/225 (6 %), p < 0.01. However, multivariate logistic regression found baseline CCI > 2 as the only independent predictor of LOS > 1 day (OR = 3.2, p = 0.03), controlling for age, race, BMI, Gleason score, tumor stage, blood loss, operative time, and occurrence of complication. In our experience, baseline patient comorbidity, quantified by CCI, was the only independent predictor of hospital LOS greater than 1 day following RARP. Preoperative assessment of patient comorbidity should be used to better counsel patients on their anticipated postoperative course.