Comparison of Open and Robot-Assisted Kidney Transplantation in terms of Perioperative and Postoperative Outcomes.

Background: The gold standard treatment method for end-stage renal disease (ESRD) is renal transplantation (RT). RT can be done with open or minimally invasive surgical methods. We aimed to compare the outcomes between patients who underwent robot-assisted renal transplantation (RART) and open renal transplantation (ORT). Methods: Data of the patients who underwent ORT or RART in two institutions between June 2015 and February 2020 were retrospectively reviewed. Patients who underwent live donor RT were included, and all donor nephrectomy procedures were performed by the laparoscopic technique. Demographic data, ischemia times, anastomosis times, operation times, and postoperative complications were recorded. Results: 98 patients were included in the ORT group, while 91 patients were included in the RART group. There was a significant difference between the two groups regarding mean patient age. While total ischemia time was 86.9 ± 7 minutes in the RART group, it was calculated as 71.2 ± 3.3 minutes in the ORT group, with a significant difference. The anastomosis time was significantly shorter in the ORT group than in the RART group. The incision length and duration of hospital stay were significantly shorter, visual analogue scores were significantly lower, and estimated blood loss was less in the RART group than in the ORT group. Conclusion: Both ORT and RART are effective and safe methods for treating ESRD. According to our study, RART is associated with relatively longer ischemia times but lower complication rates and higher patient comfort.

99mTc-PSMA targeted robot-assisted radioguided surgery during radical prostatectomy and extended lymph node dissection of prostate cancer patients.

OBJECTIVE: The feasibility of tracer production of 99mtechnetium (Tc)-prostate-specific membrane antigen (PSMA)-I&S sterile cold kit, imaging with single photon emission tomography/computed tomography (SPECT/CT), and 99mTc-PSMA-radioguided robot-assisted laparoscopic radical prostatectomy (99mTc-PSMA-RG-RALRP) technique for lymph node (LN) dissection of primary prostate cancer (PCa) patients were evaluated prospectively. METHODS: Fifteen primary PCa patients with intermediate- or high-risk score according to D'Amico risk stratification who had PSMA receptor affinity with Ga-68 PSMA-11 PET/CT were enrolled. After 99mTc-PSMA-I&S injection and SPECT/CT imaging, 99mTc-PSMA-RG-RALRP with DaVinci XI robotic platform and laparoscopic gamma probe were performed. Radioactive rating of resected tissue was compared with post-operative histopathology. Physiological and pathological uptakes of organs and tissues for both imaging modalities were compared. RESULTS: Physiological radiotracer distribution was similar for both imaging modalities. PCa lesions were much more visible on PET/CT. Metastatic LNs could not be visualized with SPECT/CT. Eighteen of 297 totally dissected LNs were metastatic, which were exactly the same with per-operative probe counts with sensitivity, specificity, accuracy, and negative and positive predictive value of all 100%. The median follow-up was 23.5 ± 4.6 months. tPSA reduction was > 98%. The 2.5 years biochemical recurrence-free survival, PCa-specific treatment-free survival and overall survival rates were 86,7%, 66,7% and 100%, respectively. CONCLUSION: Tc-99 m-PSMA-RG-RALRP is a promising technique for extended pelvic lymph node dissection (ePLND) during robotic surgery, which may shorten the operation time and reduce complication risks. If LN metastases is detected during surgery with PSMA-targeted probe, it may be an early indicator of PCa-spesific treatment planning. Tc-99 m-PSMA-I&S SPECT/CT is not as successful as Ga-68 PSMA-11 PET/CT for diagnosis of primary PCA lesions or LN metastases.

A multicenter-based critical analysis of laser settings during intrarenal laser lithotripsy by the Turkish academy of urology prospective study group (ACUP study).

OBJECTIVE: In this multicenter prospective study, we aimed to evaluate the use of holmium:yttrium-- aluminum-garnet laser during retrograde intrarenal surgery for kidney stones and the relationship between laser-related parameters and procedure-related perioperative parameters. MATERIAL AND METHODS: The 769 patients whose laser setting parameters (fiber thickness, number of shots, frequency (max.), laser power (max.), and total energy) were completely registered were included in this study program. The intraoperative ureteral lesions were evaluated using postureteroscopic lesion scale (PULS) scores and the postoperative complications with the modified Clavien-Dindo classification system. RESULTS: The maximum levels of laser power and the frequency were used in the middle calyceal stones; the value of total energy consumed was found to be higher gain in cases with multiple stones (all parameters P < .05). There was a significant positive correlation among (mean number of shots [P < .001, r » 0.46], frequency [P » .009, r » 0.1], maximum power [P < .001, r » 0.11], total energy [P < .001, r » 0.25]), anesthesia time (P < .001, r » 0.42), surgery time (P < .001, r » 0.47), and stone size. The mean number of shots increased (P < .001, r » 0.25), and the frequency level decreased (P < .001, r » -0.17) significantly with increasing Hounsfield unit (HU) values. Again, the mean number of shots and maximum laser power increased in correlation with the increasing hospitalization time (P » .004, r » 0.09 and P » .02, r » 0.07, respectively). In addition, it was observed that higher laser subparameter values and thicker fibers were used in PULS grade 2. CONCLUSION: As the stone size and HU values increased, laser-setting parameters were found to show significant variability. The increase in different parameters of the laser setting was found to be associated with longer anesthesia time, surgery time, and hospitalization period and increased risk of local trauma with PULS grade.

Relationship of MRI-measured pelvimetric dimensions and surgical positions with anaesthesia parameters in robotic perineal prostatectomy. / Influencia entre las dimensiones pélvicas medidas por RMN y las posiciones quirúrgicas en parámetros anestésicos durante la prostatectomía radical robótica perineal.

INTRODUCTION AND OBJECTIVE: Theaim of this study was to determine the effect formedby pelvic diameters preoperatively measured throughmultiparametric magnetic resonance imaging (mp-MRI) and different surgical positions on anesthesiaparameters used during perineal robot-assisted radicalprostatectomy (p-RARP). MATERIALS AND METHODS: Six different pelvimetricdimensions were determined preoperatively.Respiratory and hemodynamic variables of the patientswere measured separately and repeatedly in thesupine position, exaggerated lithotomy position at thebeginning of the 15° Trendelenburg position and the60th minute of insufflation. RESULTS: There was a significant increase in thepartial pressure of oxygen (PaO2) in the exaggeratedlithotomy position compared to the supine position.There was no significant change in the partial pressureof carbon dioxide (PCO2) in the exaggerated lithotomyposition compared to the supine position. In the 60thminute of insufflation, there was a significant increasein the PCO2 compared to the supine and exaggerated lithotomy positions. There was no statistically significantchange in the end-tidal carbon dioxide tension(EtCO2), with surgical position or insufflation time. Asignificant negative correlation was observed betweenthe distance of the ischial spines (ISD) and PCO2 change,and a significant positive correlation was observedbetween the angle of the symphysis pubis-seminalvesicles (ASS) and PCO2 change. A significant positivecorrelation was observed between the ASS value andEtCO2 change between the 60th minute of insufflationand exaggerated lithotomy position. CONCLUSION: In our study, the effect caused by differingpelvimetric diameters, surgical positions, andduration of anesthesia during p-RARP on anesthesiaparameters were shown.

INTRODUCCIÓN Y OBJETIVO: Determinarel efecto de los diámetros pélvicos preoperatoriosmedidos a través de la resonancia magnética multiparamétrica(RMNmp) y las diferentes posicionesquirúrgicas en los parámetros anestésicos durante laprostatectomía radical perineal. MATERIAL Y MÉTODOS: Se midieron seis dimensionespélvicas preoperatorias diferentes. Las variablesrespiratorias y hemodinámicas se midieron de formaseparada y repetida en las posiciones de decúbito supino,litotomía forzada al inicio del Trendelemburg a15º y a los 60min de insuflación. RESULTADOS: Se registró un aumento significativo dela presión parcial de oxigeno (PaO2) en litotomía forzada comparada a la posición de decúbito supino. Nohubo cambios significativos en la presión de dióxidode carbono (PCO2) en litotomía forzada comparada condecúbito supino. A los 60min de insuflación, hubo unaumento significativo de la PCO2 comparado con decúbitosupino y litotomía forzada. No hubo cambiossignificativos en la presión máxima de CO2 al final dela espiración (EtCO2) con las posiciones o el tiempo deinsuflación. Se observó una correlación negativa entrela distancia entre las espinas isquiáticas (EEII) y elcambio de PCO2, mientras que se observó correlaciónpositiva entre el ángulo de la sínfisis del pubis-vesículasseminales y el cambio de PCO2. Una correlaciónpositiva se observó entre el valor del ángulo sínfisispubis-vesículas seminales y EtCO2 con respecto a lainsuflación al minuto 60 y la litotomía forzada. CONCLUSIÓN: En nuestro estudio se demuestra lainfluencia de los diámetros pélvicos, las posicionesquirúrgicas y la duración de la anestesia en los parámetrosanestésicos durante la prostatectomía radicalrobótica perineal.

The Impact of Visible Tumor (PI-RADS ≥ 3) on Upgrading and Adverse Pathology at Radical Prostatectomy in Low Risk Prostate Cancer Patients: A Biopsy Core Based Analysis.

BACKGROUND: The objective of this study was to investigate the impact of the characteristics of a single visible tumor (Prostate Imaging-Reporting and Data System [PI-RADS]≥3) on upgrading and adverse pathology at radical prostatectomy (RP) in biopsy naïve low risk prostate cancer (PCa) patients. MATERIALS AND METHODS: We retrospectively reviewed 64 biopsy naïve patients from 3 different referral centers between 2018 and 2020 with a PSA<10, cT1c disease, a single PI-RADS≥ 3 index lesion in multiparametric-MRI (mp-MRI), all bearing a GG 1 tumor sampled software fusion biopsy, who underwent RP. Preoperative clinical variables including the localization, number and tumor burden of positive cores for each PI-RADS category were related to upgrading and adverse pathology (GG>2 and/or pT3 and/or lymph node positive disease) at RP. RESULTS: Overall 37 patients (57.8%) were upgraded with a significant difference of upgrading in PI-RADS3 (30.0%) versus PI-RADS 4 (67.6%) (P = .007) and PI-RADS 4-5 (70.5%) lesions (P = .002). Thirty-three of 37 GG1 tumors were upgraded to GG2, while 6 of these 33 (18.2%) had adverse pathology as well. Overall 9 patients (14.1%) had adverse pathology at RP all harboring PI-RADS4-5 lesions. The number of positive cores differed significantly between the upgraded and nonupgraded patients. Adverse pathology group had significantly higher tumor volume at RP. CONCLUSION: PI-RADS4-5 lesions are the independent predictors of upgrading and adverse pathology in low risk PCa with visible tumors. Upgrading and adverse pathology were closely related to the number of positive combined cores reflecting the role of tumor volume. This should be kept in mind in shared decision making of an individual patient with low risk disease and a visible tumor.

Comparison of Tumor Enucleation and Standard Partial Nephrectomy According to Trifecta Outcomes: A Multicenter Study by the Turkish Academy of Urology, Uro-Oncology Working Group.

INTRODUCTION: We aimed to evaluate the impact of the resection technique (tumor enucleation (TE) or standard partial nephrectomy (SPN)) on trifecta outcomes in patients having undergone partial nephrectomy (PN). MATERIALS AND METHODS: We retrospectively analyzed the clinical and pathologic parameters in patients with localized renal cell carcinoma (pT1-2N0M0) who had undergone PN between January 2001-December 2018 at one of 15 different tertiary referral centers. Multivariable logistic regression analysis was applied to investigate independent predictors of trifecta failure, decreased postoperative renal functions (decreased estimated glomerular filtration rate (eGFR) > 10%), perioperative complications (Clavien-Dindo > 1), and positive surgical margins. RESULTS: A total of 1070 patients with a mean age 56.11 ± 11.88 years were included in our study. PN was performed with TE in 848 (79.25%) and SPN in 222 (20.75%) patients. Trifecta failure rate was 56.2% for TE and 64.4% for SPN (p = 0.028). On multivariable analysis, TE was associated with less trifecta failure (p = 0.025) and eGFR decrease >10% rates (p = 0.024). On the other hand, there was no statistically significant difference between TE and SPN according to positive surgical margins (p = 0.450) and complication > Clavien-Dindo grade 1 (p = 0.888) rates. The only independent predictive factor for complications > Clavien-Dindo 1 was the Charlson comorbidity index (CCI) (p = 0.001). CONCLUSION: TE is associated with less trifecta failure than SPN. This result is mainly due to better preservation of renal function with TE.

Robotic perineal radical prostatectomy in a patient with a pre-existing three piece inflatable penile prosthesis.

Radical prostatectomy (RP) is the primary and standard treatment for localized prostate cancer. As in many surgical procedures, RP can now be accomplished through minimally invasive methods. RP in a patient with a pre-existing 3-piece inflatable penile prosthesis (IPP) is an exceptional condition and involves coping with many difficulties. In this case report, we aimed to present a patient with pre-existing 3-piece IPP for whom we successfully performed robotic perineal RP (r-PRP).

Relationship between survival outcomes and microsatellite instability, tumor infiltrating lymphocytes and programmed cell death ligand-1 expression in patients with bladder cancer and radical cystectomy.

PURPOSE: Platin-based chemotherapies are first-line treatment methods after surgery in bladder cancer. Recently, novel immunotherapies emerged after platin-based regimens. The purpose of this study was to evaluate the prognostic significance of microsatellite instability (MSI), tumor infiltrating lymphocytes (TILs) and programmed cell death ligand-1 (PD-L1) expression which are used as predictive biomarkers in immunotherapy. METHODS: Clinical and pathological features of bladder cancer patients who underwent radical cystectomy were retrospectively analyzed from their records in this single-center study. PD-L1, PD-L1 on TIL, PMS2, MSH2, MSH6 and MLH1 immunohistochemistry staining were carried out to archieve resected tumor specimens of the eligible patients. MSI was evaluated according to existing of PMS2, MSH2, MSH6 and MLH1. RESULTS: MSI was high in 24.6% of 61 patients. PD-L1 expression on tumor cells and PD-L1 expression on TIL were positive in 14.8% and 16.4% of the patients, respectively. Intratumoral TIL rate was >10% in 12 patients (19.7%). There was no statistically significant relationship between PD-L1, PD-L1 on TIL, MSI and TIL rate and patients' characteristics including sex, stage, pathologic grade and lymph node status. There was a positive trend between MSI-high patients and overall survival (OS) (p=0.089). Univariate analysis did not reveal any significant difference at 3-years OS with PD-L1 tumor expression and PD-L1 expression on TIL and TIL rate >10% (p=0.822, p=0.638, p=0.318, respectively) Conclusion: This study revealed that there is a positive trend between OS and MSI but no prognostic significance of PD-L1 and TIL which are proven predictive biomarkers of immunotherapy in patients with bladder cancer.

Machine learning algorithms can more efficiently predict biochemical recurrence after robot-assisted radical prostatectomy.

OBJECTIVES: To develop a model for predicting biochemical recurrence (BCR) in patients with long follow-up periods using clinical parameters and the machine learning (ML) methods. MATERIALS METHOD: Patients who underwent robot-assisted radical prostatectomy between January 2014 and December 2019 were retrospectively reviewed. Patients who did not have BCR were assigned to Group 1, while those diagnosed with BCR were assigned to Group 2. The patient's demographic data, preoperative and postoperative parameters were all recorded in the database. Three different ML algorithms were employed: random forest, K-nearest neighbour, and logistic regression. RESULTS: Three hundred and sixty-eight patients were included in this study. Among these patients, 295 (80.1%) did not have BCR (Group 1), while 73 (19.8%) had BCR (Group 2). The mean duration of follow-up and duration until the diagnosis of BCR was calculated as 35.2 ± 16.7 and 11.5 ± 11.3 months, respectively. The multivariate analysis revealed that NLR, PSAd, risk classification, PIRADS score, T stage, presence or absence of positive surgical margin, and seminal vesicle invasion were predictive for BCR. Classic Cox regression analysis had an area under the curve (AUC) of 0.915 with a sensitivity and specificity of 90.6% and 79.8%. The AUCs for receiver-operating characteristic curves for random forest, K nearest neighbour, and logistic regression were 0.95, 0.93, and 0.93, respectively. All ML models outperformed the conventional statistical regression model in the prediction of BCR after prostatectomy. CONCLUSION: The construction of more reliable and potent models will provide the clinicians and patients with advantages such as more accurate risk classification, prognosis estimation, early intervention, avoidance of unnecessary treatments, relatively lower morbidity and mortality. The ML methods are cheap, and their powers increase with increasing data input; we believe that their clinical use will increase over time.

Is neutrophile to lymphocyte ratio a predictor of Gleason score upgrading according to risk classifications in patients with prostate cancer.

OBJECTIVES: We aimed to determine the parameters that predict Gleason Score (GS) upgrading in patients undergoing robot-assisted laparoscopic radical prostatectomy (RARP) and especially the ability of neutrophile to lymphocyte ratio (NLR) in predicting the upgrading. METHODS: Patients who underwent RARP for prostate cancer in our clinic between January 2013 and January 2018 were retrospectively analyzed. Patients' demographic data, preoperative and postoperative parameters were all recorded in the database. NLR was calculated by dividing the absolute neutrophil count (NC) by the absolute lymphocyte count (LC). Patients were classified as low, moderate and high risk according to the National Comprehensive Cancer Network (NCNN) Guidelines. Any increase in GS between biopsy results and radical prostatectomy specimens were consideredas an GS upgrading. RESULTS: After applying the inclusion and exclusion criteria, a total of 571 patients, 205 patients without GS upgrading (Group 1) and 366 patients with GS upgrading (Group 2), were included. The mean preoperative PSA values and prostate volumes were 10.8 ± 8 ng/dL and 45 ± 18.8 ml, respectively. Group 2 had a significantly high NC and NLR, significantly low platelet count (PC) and LC, (p=0.0001, 0.0001, 0.001 and0.002, respectively). Group 2 was found to have significantly higher positive surgical margin (PSM), extraprostatic extension (EPE) and seminal vesical invasion (SVI) (p<0.001). There was no significant correlation between the parameters of NLR and PSM, EPE, SVI, and lymph node invasion (LNI). Binomial logistic regression showed patients with increased NLR had 1.68 times higher odds to exhibit an upgrade in GS in the post-surgical histopathological analysis. CONCLUSIONS: NLR calculated preoperatively is an easy diagnostic method that can predict GS upgrading in patients scheduled for radical prostatectomy for prostate cancer.

OBJETIVOS: Determinamos los parámetros que predicen el grado de sobregradación de Gleason en pacientes que recibieron prostatectomía radical robótica asistida por laparoscopia (PRRL) y especialmente la habilidad de la tasa de neutrófilos/linfocitos (NLR) a la hora de predecir la sobregradación.MÉTODOS: Los pacientes que recibieron PRRL por cáncer de próstata en nuestra clínica entre enero 2013 y enero de 2018 se analizaron retrospectivamente. Los datos demográficos, parámetros preoperatorios y postoperatorios fueron reportados en la base de datos. NLR se calculo dividiendo el numero absoluto de neutrófilos (NC) por el numero absoluto de linfocitos (LC). Los pacientes se clasificaron como bajo, moderado y alto riesgo en la relación a las guías de National Comprehensive Cancer Network (NCNN). Cualquier aumento en el grado de Gleason entre los resultados de la biopsia y la prostatectomía radical fueron considerados como una sobregradación de grado deGleason. RESULTADOS: Después de aplicar los criterios de inclusión y exclusión, un total de 571 pacientes, 205 sin sobregradación de Gleason (Grupo 1) y 366 pacientes con sobregradación de Gleason (Grupo 2). La media de PSA preoperatorio y volúmenes prostáticos fueron de 10,8 ± 8 ng/dL y 45 ± 18,8 ml, respectivamente. El grupo 2 presentó un NC y NLR más alto, significativamente, bajos niveles de plaquetas y LC (p=0,0001, 0,0001, 0,001 y 0,002, respectivamente). El grupo 2 demostró tener niveles significativamente más altos de márgenes quirúrgicos (PSM), extensión extraprostatica (EPE) e invasión de vesículas seminales (SVI) (p<0,001). No se econtró una correlación significativa entre los parámetros de NLR y PSM, EPE, SVI, invasión ganglios linfáticos. El modelo de regresión binomial logística demostró que los pacientes con un incremento de NLR tuvieron 1,68 más veces de tener una sobregradación de Gleason en el análisis histopatológico postquirúrgico. CONCLUSIONES: El cálculo de NLR preoperatorio es un método fácil de diagnóstico que puede predecir la sobregradación de Gleason en pacientes que van a recibir una prostatectomía radical por cáncer de próstata.

Can robot-assisted kidney transplantation provide higher quality of life than open kidney transplantation during the early postoperative period?

PURPOSE: Purpose of this study is to investigate the quality of life (QoL) in patients with end-stage renal disease who underwent open or robot-assisted kidney transplantation (OKT and RAKT). MATERIALS AND METHODS: Patients who underwent OKT and RAKT at Bakirkoy Sadi Konuk Training and Research Hospital between June 2016 and December 2018 constituted the target population of this study. The patient group was divided into two groups as per the surgical technique (ie, open vs. robot-assisted). Demographic data, preoperative and postoperative data of all patients were collected prospectively. The QoL of the patients was assessed preoperatively and on the postoperative 30th day. RESULTS: Sixty-seven patients who underwent OKT and 60 patients who underwent RAKT were included. The mean patient age and BMI were calculated as 40.9 ± 11.6 years and 24.4 ± 2.9 kg/m2 , respectively. Patients in the RAKT group were significantly younger than the patients in the OKT group (P = .002). There were no significant differences between the two groups in terms of gender, BMI, ASA and the ratio of premptive patients. The mean preoperative hemoglobin level was significantly higher in the OKT group than the RAKT group (P = .003). While mean total ischemia time was shorter in the "open" group, intraoperative blood loss and incision length were shorter in the RAKT group. Duration of surgical drainage and hospital stay was shorter in the "robot-assisted" group. There was no significant difference between the groups in terms of SF-36 subparameters preoperatively. The physical component scores of the QoL questionnaire revealed that postoperative impairment of quality of life in the early postoperative period was more significant in the OKT than the RAKT. CONCLUSION: Patients who underwent RAKT have a higher QoL than the patients who were treated with OKT as per their self-reported QoL scores in the early postoperative period.

Robot-assisted kidney transplantation: update from the European Robotic Urology Section (ERUS) series.

OBJECTIVE: To report the results of the robot-assisted kidney transplantation (RAKT) experience performed in 10 European centres by members of the European Robotic Urology Section (ERUS)-RAKT group. PATIENTS AND METHODS: This is a multicentre prospective observational study of RAKT. Descriptive analysis of recipients and donor characteristics, surgical data, intraoperative outcomes, complications rate and functional results were collected and analysed. RESULTS: Between July 2015 and September 2019, 291 living-donor RAKTs were performed. Recipients were mostly male (189 [65%]), the mean Standard deviation (sd) age was 45.2 (13.35) years, the mean (sd) body mass index was 27.13 (19.28) kg/m2 , and RAKT was pre-emptive in 155 (53.8%) cases. Right and multiple arteries kidneys were used in 15.4%. The mean (sd) total surgical and re-warming time was 244 (70.5) min and 53.16 (15.27) min, respectively. In all, 17 patients presented with postoperative bleeding (5.7%). Five kidneys had delayed graft function; five (2%) were lost due to thrombosis and one due to acute rejection. Two patients had arterial stenosis, three had incisional hernias, six had ureteric stenosis, and nine had lymphoceles. Neither surgical nor re-warming times were correlated with postoperative serum creatinine levels (P > 0.05). Comparison of surgical data between the first 120 cases and the following 171 cases showed a significantly shorter total surgical time in the second group (265 vs 230 min, P = 0.005). CONCLUSIONS: This is the largest European multicentre study of RAKT with good surgical and functional results competitive with open kidney transplant series, with a relatively short learning curve when performed in centres with a wide experience in open kidney transplantation and robotic surgery.

Retrograde intrarenal surgery of renal stones: a critical multi-aspect evaluation of the outcomes by the Turkish Academy of Urology Prospective Study Group (ACUP Study).

AIMS: To outline and evaluate the incidence, management and follow-up of the residual fragments (RFs) following retrograde intrarenal surgery (RIRS) of renal stones by the Turkish Academy of Urology Prospective Study Group (ACUP Study). METHODS: Following the ethical committee approval, 15 centers providing data regarding the incidence, management, and follow-up of RFs after RIRS were included and all relevant information was recorded into the same electronic database program ( https://acup.uroturk.org.tr/ ) created by Turkish Urology Academy for Residual Stone Study. RESULTS: A total of 1112 cases underwent RIRS for renal calculi and RFs were observed in 276 cases (24.8%). Of all the parameters evaluated, our results demonstrated no statistically significant relation between preoperative DJ stenting and the presence of RFs (χ2 (1) = 158.418; p = 0.099). RFs were significantly higher in patients treated with UAS (82 patients, 29.3%) during the procedure compared to the cases who did not receive UAS (194 patients, 23.3%) (χ2 (1) = 3.999; p = 0.046). The mean period for a secondary intervention after RIRS was 28.39 (± 12.52) days. Regarding the procedures applied for RF removal, re-RIRS was the most commonly performed approach (56%). CONCLUSIONS: Despite the reported safe and successful outcomes, the incidence of RFs is higher, after the RIRS procedure particularly in cases with relatively larger calculi. Such cases need to be followed in a close manner and although a second flexible ureteroscopy is the treatment of choice for fragment removal in the majority of these patients, shock wave lithotripsy and percutaneous nephrolithotomy may also be preferred in selected cases.

Robotic-assisted kidney transplantation in obese recipients compared to non-obese recipients: the European experience.

PURPOSE: The main objective was to compare minor (Clavien I-II) and major (Clavien ≥ III) intra- and postoperative complications of living donor robotic assisted kidney transplantation (RAKT) in obese (≥ 30 kg/m2 BMI), overweight (< 30/ ≥ 25 kg/m2 BMI) and non-overweight recipients (< 25 kg/m2 BMI). METHODS: For the present retrospective study, we reviewed the multi-institutional ERUS-RAKT database to select consecutive living donor RAKT recipients. Functional outcomes, intra- and postoperative complications were compared between obese, overweight and non-overweight recipients. RESULTS: 169 living donor RAKTs were performed, by 10 surgeons, from July 2015 to September 2018 in the 8 European centers. 32 (18.9%) recipients were obese, 66 (39.1%) were overweight and 71 (42.0%) were non-overweight. Mean follow-up was 1.2 years. There were no major intra-operative complications in either study group. Conversion to open surgery occurred in 1 obese recipient, in 2 overweight recipients and no conversion occurred in non-overweight recipients (p = 0.3). Minor and major postoperative complications rates were similar in the 3 groups. At one-year of follow-up, median eGFR was similar in all groups [54 (45-60) versus 57 (46-70) versus 63 (49-78) ml/min/1.73 m2 in obese, overweight and non-overweight recipient groups, respectively, p = 0.5]. Delayed graft function rate was similar in the 3 groups. Only the number of arteries was an independent predictive factor of suboptimal renal function at post-operative day 30 in the multivariate analysis. CONCLUSION: RAKT in obese recipients is safe, compared to non-overweight recipients and yields very good function, when it performed at high-volume referral centers by highly trained transplant teams.

Effect of pelvimetric diameters on success of surgery in patients submitted to robot-assisted perineal radical prostatectomy

ABSTRACT Objective: Minimally invasive techniques are used increasingly by virtue of advancements in technology. Surgery for prostate cancer, which has high morbidity, is performed with an increasing momentum based on the successful oncological and functional outcomes as well as cosmetic aspects. Materials and methods: Sixty two patients underwent robot-assisted perineal radical prostatectomy (R-PRP) surgery at our clinic between November 2016 and August 2017. Six pelvimetric dimensions were defined and measured by performing multiparametric magnetic resonance imaging (mpMRI) prior to operation in all patients. In light of these data, we aimed to investigate the effect of pelvimetric measurements on surgery duration and surgical margin positivity. Results: By using this technique in pelvic area, we observed that measurements only representing surgical site and excluding other pelvic organs had a significant effect on surgery duration, and pelvic dimensions had no significant effect on surgical margin positivity. Conclusion: In R-PRP technique, peroperative findings and oncological outcomes can vary depending on several variable factors, but although usually not taken into account, pelvimetric measurements can also affect these outcomes. However, there is a need for randomised controlled trials to be conducted with more patients.

Gasless robotic perineal radical prostatectomy: Experience of the first 12 cases. / Prostatectomía radical perineal robótica sin gas: experiencia en los primeros 12 casos.

OBJECTIVE: To present our results of first 12 patients on whom we performed gasless robotic perineal radical prostatectomy (r-PRP). METHODS: We performed gasless r-PRP on 12 patients between August 2018 and October 2018. Multiparametric magnetic resonance imaging was performed forall patients to exclude local advanced disease. Demographic characteristics, technical details, and intra and postoperative data were analyzed. RESULTS: The mean age of the patients was 62.6 ± 6years. The mean body mass index of the patients was 27 ± 4 kg/m2. Four patients had a history of major abdominal surgery. The mean preoperative prostate-specific antigen (PSA) was 7.4 ± 2.5 ng/mL. The mean prostate volume was 40 ± 10.2 cc. The mean perineal dissection time was 45.6 ± 5.8 minutes. The mean console time and total operative time were 117.8 ± 28.1 and 163.3 ± 30.7 minutes, respectively. The mean urethral catheter removal time was 9.2 ± 1.9 days. The immediate continence rate was 25% after the urethral catheter removal and the continence rate was 75% and 91.67% at the 3rd and 6th month follow-up, respectively. CONCLUSIONS: Gasless r-PRP is an efficient and safe method in prostate cancer surgery. However, prospective randomized and comparative studies are required with large patient series.

OBJETIVO: Presentar nuestros resultados en los primeros 12 pacientes en los que hemos realizado prostatectomía radical perineal robotica sin gas.MÉTODOS: Se realizó la prostatectomia radical robótica perineal sin gas en 12 casos entre agosto 2018 y octubre 2018. RNM multiparamétrica se realizó en todos los pacientes para excluir enfermedad avanzada local. Las características demográficas, detalles técnicos y datos intra e postoperatorios fueron analizados. RESULTADOS: La mediana de edad de los pacientes fue de 62,6 ± 6 años. El IMC medio fue de 27 ± 4 kg/m2, cuatro pacientes tenían historia de cirugía abdominal previa. EL PSA preoperatorio fue de 7,4 ± 2,5 ng/mL. El tamaño prostático medio fue de 40 ± 10,2 cc. El tiempo medio de disección perineal fue de 45,6 ± 5,8 minutos. El tiempo medio de consola y el tiempo quirúrgico total fueron de 117,8 ± 28,1 y 163,3 ± 30,7 minutos, respectivamente. El tiempo medio a la retirada de sonda fue de 9,2 ± 1,9 dias. La continencia inmediata fue de 25% después de la retirada de la sonda y la tasa de continencia fue de 75% y 92% al 3r y 6º mes de seguimiento, respectivamente. CONCLUSIONES: La prostatectomía radical robótica perineal sin gas es un procedimiento eficiente y seguro en la cirugía del cáncer de próstata. Aunque estudios prospectivos randomizados y estudios comparativos son necesarios con más series de pacientes.

Gasless robotic perineal radical prostatectomy: experience of the first 12 cases / Prostatectomía radical perineal robótica sin gas: experiencia en los primeros 12 casos

OBJECTIVE: To present our results of first 12 patients on whom we performed gasless robotic perineal radical prostatectomy (r-PRP). METHODS: We performed gasless r-PRP on 12 patients between August 2018 and October 2018. Multiparametric magnetic resonance imaging was performed for all patients to exclude local advanced disease. Demographic characteristics, technical details, and intra and postoperative data were analyzed. RESULTS: The mean age of the patients was 62.6 ± 6 years. The mean body mass index of the patients was 27 ± 4 kg/m2. Four patients had a history of major abdominal surgery. The mean preoperative prostate-specific antigen (PSA) was 7.4 ± 2.5 ng/mL. The mean prostate volume was 40 ± 10.2 cc. The mean perineal dissection time was 45.6 ± 5.8 minutes. The mean console time and total operative time were 117.8 ± 28.1 and 163.3 ± 30.7 minutes, respectively. The mean urethral catheter removal time was 9.2 ± 1.9 days. The immediate continence rate was 25% after the urethral catheter removal and the continence rate was 75% and 91.67% at the 3rd and 6th month follow-up, respectively. CONCLUSIONS: Gasless r-PRP is an efficient and safe method in prostate cancer surgery. However, prospective randomized and comparative studies are required with large patient series

OBJETIVO: Presentar nuestros resultados en los primeros 12 pacientes en los que hemos realizado prostatectomía radical perineal robótica sin gas. MÉTODOS: Se realizó la prostatectomia radical robótica perineal sin gas en 12 casos entre agosto 2018 y octubre 2018. RNM multiparamétrica se realizó en todos los pacientes para excluir enfermedad avanzada local. Las características demográficas, detalles técnicos y datos intra e postoperatorios fueron analizados. RESULTADOS: La mediana de edad de los pacientes fue de 62,6 ± 6 años. El IMC medio fue de 27 ± 4 kg/m2, cuatro pacientes tenían historia de cirugía abdominal previa. EL PSA preoperatorio fue de 7,4 ± 2,5 ng/mL. El tamaño prostático medio fue de 40 ± 10,2 cc. El tiempo medio de disección perineal fue de 45,6 ± 5,8 minutos. El tiempo medio de consola y el tiempo quirúrgico total fueron de 117,8 ± 28,1 y 163,3 ± 30,7 minutos, respectivamente. El tiempo medio a la retirada de sonda fue de 9,2 ± 1,9 días. La continencia inmediata fue de 25% después de la retirada de la sonda y la tasa de continencia fue de 75% y 92% al 3r y 6º mes de seguimiento, respectivamente. CONCLUSIONES: La prostatectomía radical robótica perineal sin gas es un procedimiento eficiente y seguro en la cirugía del cáncer de próstata. Aunque estudios prospectivos randomizados y estudios comparativos son necesarios con más series de pacientes

Effect of pelvimetric diameters on success of surgery in patients submitted to robot-assisted perineal radical prostatectomy.

OBJECTIVE: Minimally invasive techniques are used increasingly by virtue of advancements in technology. Surgery for prostate cancer, which has high morbidity, is performed with an increasing momentum based on the successful oncological and functional outcomes as well as cosmetic aspects. MATERIALS AND METHODS: 62 patients underwent robot-assisted perineal radical prostatectomy (R-PRP) surgery at our clinic between November 2016 and August 2017. Six pelvimetric dimensions were defined and measured by performing multiparametric magnetic resonance imaging (mpMRI) prior to operation in all patients. In light of these data, we aimed to investigate the effect of pelvimetric measurements on surgery duration and surgical margin positivity. RESULTS: By using this technique in pelvic area, we observed that measurements only representing surgical site and excluding other pelvic organs had a significant effect on surgery duration, and pelvic dimensions had no significant effect on surgical margin positivity. CONCLUSION: In R-PRP technique, peroperative findings and oncological outcomes can vary depending on several variable factors, but although usually not taken into account, pelvimetric measurements can also affect these outcomes. However, there is a need for randomised controlled trials to be conducted with more patients.

Robot-assisted radical perineal prostatectomy: a review of 95 cases.

OBJECTIVES: To assess the early functional and oncological outcomes of a large series of patients who underwent robot-assisted radical perineal prostatectomy (RPP). MATERIALS AND METHODS: We retrospectively analysed the patients who underwent robot-assisted RPP for localized prostate cancer between November 2016 and September 2018. Patients who had locally advanced disease proven on biopsy or were suspected to have locally advanced disease on multiparametric magnetic resonance imaging and patients who had a contraindication for the exaggerated lithotomy position were not included in this study. Patient demographics, preoperative and postoperative variables, complications and follow-up times were recorded. RESULTS: A total of 95 patients were included. Their mean ± sd age was 61.5 ± 6.5 years. The median (interquartile range [IQR]) preoperative prostate-specific antigen level was 6.1 (3.7) ng/mL, the median (IQR) operating time was 140 (25) min, and the mean ± sd blood loss was 67.4 ± 17 mL. Pelvic lymph node dissection (PLND) was performed for 12 patients (12.6%). The median (IQR) hospital stay was 1 (1) days. Positive surgical margins were present in eight patients (8.4%). After catheter removal, the immediate continence rate was 41%. Continence rates were 78%, 87% and 91%, respectively, 3, 6 and 12 months after surgery. Potency rates were 49%, 69% and 77%, respectively, 3, 6 and 12 months after surgery for patients who had adequate potency preoperatively. The median (IQR) follow-up time was 13 (3.1) months. CONCLUSION: We conclude that robot-assisted RPP is a reliable and effective surgical technique that can be employed in the treatment of localized prostate cancer regardless of prostate volume, especially in patients with a history of abdominal surgery. As an additional advantage, PLND can be performed through the same incision.

Learning Curve in Robot-assisted Kidney Transplantation: Results from the European Robotic Urological Society Working Group.

BACKGROUND: Recently, robot-assisted kidney transplantation (RAKT) was recently introduced as renal replacement mini-invasive surgery. OBJECTIVE: To report surgical technique, including tips and tricks, and the learning curve for RAKT. DESIGN, SETTING, AND PARTICIPANTS: All consecutive RAKTs performed in the five highest-volume centers of the European Robotic Urological Society RAKT group were reviewed, and a step-by-step description of the technique was compiled. SURGICAL PROCEDURE: Surgeries were performed with Da Vinci Si/Xi. The patient was placed in the lithotomy position. The Trendelenburg position was set at 20-30° and the robot was docked between the legs. MEASUREMENTS: Shewhart control charts and cumulative summation (CUSUM) graphs and trifecta were generated to assess the learning curve according to rewarming time (RWT), intra/postoperative complications, and renal graft function (glomerular filtration rate) on days 7 and 30, and at 1 yr. Linear regressions were performed to compare the learning curves of each surgeon. RESULTS AND LIMITATIONS: Arterial anastomosis time was below the alarm/alert line in 93.3%/88.9% of RAKTs, while venous anastomosis time was below the alarm/alert line in 88.9%/73.9%. The nonanastomotic RWT exceeded +3 standard deviation (SD) in 24.7% of procedures and +2SD in 37.1%. In only 46% cases, the RWT was below the alert line. The ureteroneocystostomy time was below +2SD and +3SD in 87.9% and 90.2% of cases, respectively. CUSUM showed that the learning curve for arterial anastomosis required up to 35 (mean = 16) cases. Complications and delayed graft function rates decreased significantly and reached a plateau after the first 20 cases. Trifecta was achieved in 75% (24/32) of the cases after the first 34 RAKTs in each center. CONCLUSIONS: A minimum of 35 cases are necessary to reach reproducibility in terms of RWT, complications, and functional results. PATIENT SUMMARY: Robot-assisted kidney transplantation requires a learning curve of 35 cases to achieve reproducibility in terms of timing, complications, and functional results. Synergy between the surgeon and the assistant is crucial to reduce rewarming time. High-grade complications and delayed graft function are rare after ten surgeries. Hands-on training and proctorship are highly recommended.