Predictors of Same-Day Discharge after Single-Port Transvesical Enucleation of the Prostate (STEP).

OBJECTIVES: To determine the rate of outpatient cases and identify predictors for same-day discharge (SDD) after single-port transvesical enucleation of the prostate (STEP). METHODS: Retrospective analysis of all consecutive STEP cases performed at a single center by three surgeons from February 2019 to October 2023. The cohort was categorized into SDD cases (<8 hours until discharge) and inpatient cases. Group comparisons were made and logistic regression was used to identify predictors of SDD. RESULTS: A total of 152 STEP cases were performed successfully without additional ports or conversions. Fifty-two patients were pre-planned admissions, leaving 100 planned outpatient cases, of which 86% were discharged on the same day (median length of stay of 4.7 hours). Comparing the groups, inpatient cases were older, had higher Charlson Comorbidity Index (CCI) scores, higher estimated blood loss (EBL) during surgery, and more intraoperative complications than SDD patients. Univariate logistic regression identified age and CCI as the predictors associated with SDD after STEP. Notably, there were no major postoperative complications or readmissions in either group. CONCLUSIONS: In our four-year experience with STEP, lower age and CCI score were significant predictors of SDD. The comprehensive evaluation criteria for discharge foster a safe recovery at home, coupled with a 0% rate of major postoperative complications and readmissions. These findings underscore the safety and efficacy of STEP, guiding patient counseling and surgeon expectations.

Transperitoneal Versus Retroperitoneal Robotic-Assisted Partial Nephrectomy in Patients with Obesity.

Introduction: We aim to compare transperitoneal (TP) and retroperitoneal (RP) robotic partial nephrectomy (RPN) in obese patients. Obesity and RP fat can complicate RPN, especially in the RP approach where working space is limited. Materials and Methods: Using a multi-institutional database, we analyzed 468 obese patients undergoing RPN for a renal mass (86 [18.38%] RP, 382 [81.62%] TP). Obesity was defined as body mass index ≥30 kg/m2*. A 1:1 propensity score matching was performed adjusting for age, previous abdominal surgery, tumor size, R.E.N.A.L nephrometry score, tumor location, surgical date, and participating centers. Baseline characteristics and perioperative and postoperative data were compared. Results: In the propensity score-matched cohort, 79 (50%) TP patients were matched with 79 (50%) RP patients. The RP group had more posterior tumors (67 [84.81%], RP versus 23 [29.11%], TP; P < .001), while the other baseline characteristics were comparable. Warm ischemia time (interquartile range; 15 [10, 12], RP versus 14 [10, 17] minutes, TP; P = .216), operative time (129 [116, 165], RP versus 130 [95, 180] minutes, TP; P = .687), estimated blood loss (50 [50, 100], RP versus 75 [50, 150] mL, TP; P = .129), length of stay (1 [1, 1], RP versus 1 [1, 2] day, TP; P = .319), and major complication rate (1 [1.27%], RP versus 3 [3.80%], TP; P = .620) were similar. No significant difference was observed in positive surgical margin rate and delta estimated glomerular filtration at follow-up. Conclusion: TP and RP RPN yielded similar perioperative and postoperative outcomes in obese patients. Obesity should not be a factor in determining optimal approach for RPN.

Association between Expression of Connective Tissue Genes and Prostate Cancer Growth and Progression.

To find an association between genomic features of connective tissue and pejorative clinical outcomes on radical prostatectomy specimens. We performed a retrospective analysis of patients who underwent radical prostatectomy and underwent a Decipher transcriptomic test for localized prostate cancer in our institution (n = 695). The expression results of selected connective tissue genes were analyzed after multiple t tests, revealing significant differences in the transcriptomic expression (over- or under-expression). We investigated the association between transcript results and clinical features such as extra-capsular extension (ECE), clinically significant cancer, lymph node (LN) invasion and early biochemical recurrence (eBCR), defined as earlier than 3 years after surgery). The Cancer Genome Atlas (TCGA) was used to evaluate the prognostic role of genes on progression-free survival (PFS) and overall survival (OS). Out of 528 patients, we found that 189 had ECE and 27 had LN invasion. The Decipher score was higher in patients with ECE, LN invasion, and eBCR. Our gene selection microarray analysis showed an overexpression in both ECE and LN invasion, and in clinically significant cancer for COL1A1, COL1A2, COL3A1, LUM, VCAN, FN1, AEBP1, ASPN, TIMP1, TIMP3, BGN, and underexpression in FMOD and FLNA. In the TCGA population, overexpression of these genes was correlated with worse PFS. Significant co-occurrence of these genes was observed. When presenting overexpression of our gene selection, the 5-year PFS rate was 53% vs. 68% (p = 0.0315). Transcriptomic overexpression of connective tissue genes correlated to worse clinical features, such as ECE, clinically significant cancer and BCR, identifying the potential prognostic value of the gene signature of the connective tissue in prostate cancer. TCGAp cohort analysis showed a worse PFS in case of overexpression of the connective tissue genes.

Partial or radical nephrectomy for complex renal mass: a comparative analysis of oncological outcomes and complications from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group.

PURPOSE: To compare outcomes of robotic-assisted partial nephrectomy (RAPN) and minimally invasive radical nephrectomy (MIS-RN) for complex renal masses (CRM). METHODS: We conducted a retrospective multicenter analysis of CRM patients who underwent MIS-RN and RAPN. CRM was defined as RENAL score 10-12. Primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS), recurrence, and complications. Multivariable analysis (MVA) and Kaplan-Meier Analysis (KMA) were used to analyze functional and survival outcomes for RN vs. PN by pathological stage. RESULTS: 926 patients were analyzed (MIS-RN = 437/RAPN = 489; median follow-up 24.0 months). MVA demonstrated lack of transfusion (HR = 1.63, p = 0.005), low-grade (HR = 1.18, p = 0.018) and smaller tumor size (HR = 1.05, p < 0.001) were associated with OS. Younger age (HR = 1.01, p = 0.017), high-grade (HR = 1.18, p = 0.017), smaller tumor size (HR = 1.05, p < 0.001), and lack of transfusion (HR = 1.39, p = 0.038) were associated with CSS. Increasing tumor size (HR = 1.18, p < 0.001), high-grade (HR = 3.21, p < 0.001), and increasing age (HR = 1.02, p = 0.009) were independent risk factors for recurrence. Type of surgery was not associated with major complications (p = 0.094). For KMA of MIS-RN vs. RAPN for pT1, pT2 and pT3, 5-year OS was 85% vs. 88% (p = 0.078); 82% vs. 80% (p = 0.442) and 84% vs. 83% (p = 0.863), respectively. 5-year CSS was 98% for both procedures (p = 0.473); 94% vs. 92% (p = 0.735) and 91% vs. 90% (p = 0.581). 5-year non-CSS was 87% vs. 93% (p = 0.107); 87% for pT2 (p = 0.485) and 92% for pT3 for both procedures (p = 0.403). CONCLUSION: RAPN in CRM is not associated with increased risk of complications or worsened oncological outcomes when compared to MIS-RN and may be preferred when clinically indicated.

Operative and oncological outcomes of salvage robotic radical and partial nephrectomy: a multicenter experience.

We aim to describe the perioperative and oncological outcomes for salvage robotic partial nephrectomy (sRPN) and salvage robotic radical nephrectomy (sRRN). Using a prospectively maintained multi-institutional database, we compared baseline clinical characteristics and perioperative and postoperative outcomes, including pathological stage, tumor histology, operative time, ischemia time, estimated blood loss (EBL), length of stay (LOS), postoperative complication rate, recurrence rate, and mortality. We identified a total of 58 patients who had undergone robotic salvage surgery for a recurrent renal mass, of which 22 (38%) had sRRN and 36 (62%) had sRPN. Ischemia time for sRPN was 14 min. The median EBL was 100 mL in both groups (p = 0.581). One intraoperative complication occurred during sRRN, while three occurred during sRPN cases (p = 1.000). The median LOS was 2 days for sRRN and 1 day for sRPN (p = 0.039). Postoperatively, one major complication occurred after sRRN and two after sRPN (p = 1.000). The recurrence reported after sRRN was 5% and 3% after sRPN. Among the patients who underwent sRRN, the two most prevalent stages were pT1a (27%) and pT3a (27%). Similarly, the two most prevalent stages in sRPN patients were pT1a (69%) and pT3a (6%). sRRN and sRPN have similar operative and perioperative outcomes. sRPN is a safe and feasible procedure when performed by experienced surgeons. Future studies on large cohorts are essential to better characterize the importance and benefit of salvage partial nephrectomies.

A comparison of outcomes between transperitoneal and retroperitoneal robotic assisted partial nephrectomy in patients with completely endophytic kidney tumors.

INTRODUCTION: Retroperitoneal robotic partial nephrectomy (RPN) has been shown to have comparable outcomes to the transperitoneal approach for renal tumors. However, this may not be true for completely endophytic tumors as they pose significant challenges in RPN with increased complication rates. Hence, we sought to compare the safety and feasibility of retroperitoneal RPN to transperitoneal RPN for completely endophytic tumors. METHODS: We performed a retrospective analysis of patients who underwent RPN for a completely endophytic renal mass using either transperitoneal or retroperitoneal approach from our multi-institutional database (n = 177). Patients who had a solitary kidney, prior ipsilateral surgery, multiple/bilateral tumors, and horseshoe kidneys were excluded from the analysis. Overall, 156 patients were evaluated (112 [71.8%] transperitoneal, 44 [28.2%] retroperitoneal). Baseline characteristics, perioperative and postoperative data were compared between the surgical transperitoneal and retroperitoneal approach using Chi-square test, Fishers exact test, t test, Mood median test and Mann Whitney U test. RESULTS: Of the 156 patients in this study, 86 (56.9%) were male and the mean (SD) age was 58 (13) years. Baseline characteristics were comparable between the 2 approaches. Compared to transperitoneal approach, retroperitoneal approach had similar ischemia time (19.6 [SD = 7.6] minutes vs. 19.5 [SD = 10.2] minutes, P = 0.952), operative time (157.5 [SD = 44.8] minutes vs. 160.2 [SD = 47.3] minutes, P = 0.746), median estimated blood loss (50 ml [IQR: 50, 150] vs. 100 ml [IQR: 50, 200], P = 0.313), median length of stay (1 [IQR: 1, 2] day vs. 1 [IQR: 1, 2] day, P = 0.126) and major complication rate (2 [4.6%] vs. 3 [2.7%], P = 0.621). No difference was observed in positive surgical margin rate (P = 0.1.00), delta eGFR (P = 0.797) and de novo chronic kidney disease occurrence (P = 1.000). CONCLUSION: Retroperitoneal and transperitoneal RPN yielded similar perioperative and functional outcomes in patients with completely endophytic tumors. In well-selected patients with purely endophytic tumors, either a retroperitoneal or transperitoneal approach could be considered without compromising perioperative and postoperative outcomes.

Minimally-Invasive Radical Nephrectomy and Left-Sided Level II Caval Thrombectomy: A New Combined Technique.

OBJECTIVE: To present a combined multiport robotic and open approach for left radical nephrectomy and inferior vena cava thrombectomy in patients with a primary left renal mass and level II inferior vena cava (IVC) tumor thrombus. METHODS: A 69-year-old female was diagnosed with an 8.9cm left renal neoplasm with level II IVC thrombus. She was placed in the left-side-up flank position. The descending colon was mobilized and the left gonadal vein was identified. The left renal vein was identified and fully dissected. The left renal artery was dissected and stapled. The kidney was dissected and left detached with exception of the renal vein. The robot was undocked and the patient was positioned supine. Through a supra-umbilical midline incision, the ascending colon and duodenum were mobilized medially. The right renal vein and IVC were identified and dissected to the level of hepatic veins. The IVC was clamped using a Satinsky clamp. The right renal artery and vein remained patent during thrombectomy. The IVC was opened, the thrombus was evacuated, and IVC was closed. Clamps were removed and the kidney was removed. RESULTS: Operative time was 405 minutes. IVC clamp time was 14 minutes. Estimated blood loss was 500cc. Recovery was uncomplicated. Length of stay was 4 days. Pathology showed clear cell carcinoma with negative margins. CONCLUSION: IVC thrombectomy is challenging on left sided tumors. Combining a robotic and open technique together is feasible and allows a smaller supra-umbilical midline incision compared to standard open incision.

Single-port Extraperitoneal and Transperitoneal Radical Prostatectomy: A Multi-Institutional Propensity-Score Matched Study.

OBJECTIVE: To compare the perioperative and early postoperative outcomes between single-port (SP) extraperitoneal radical prostatectomy (EPRP) and SP transperitoneal radical prostatectomy (TPRP), in a multi-institutional setting. METHODS: We identified all patients who underwent SP robot-assisted radical prostatectomy at 6 different institutes. Data of 650 patients were collected and divided into 2 groups based on the surgical approach: SP EPRP or SP TPRP. A Propensity-score matched-pair analysis for body mass index (BMI), prostate size, and National Comprehensive Cancer Network risk was performed with a 1:1 ratio. Analysis of perioperative and postoperative outcomes was performed using Wilcoxon signed-rank test and chi-square and Fisher's exact tests. RESULTS: After matching, 238 patients were included in each arm. The median follow-up period was 7 and 6 months for EPRP and TPRP groups, respectively. The total operative time was longer in the EPRP group (206 vs 155 minutes, P < .001). The EPRP group had a shorter length of hospitalization and same-day discharge rate compared to the TPRP approach (P < .001). There was no difference in the overall intraoperative or postoperative complications rate between the 2 groups, nor positive surgical margin rates. CONCLUSION: The SP extraperitoneal approach is associated with a shorter hospital stay and higher rate of same-day discharge, with no difference in the surgical margin, or complication rates.

Standardization of Surgical Outcome Across the Tumor Complexity Spectrum in Robotic Partial Nephrectomy.

Introduction: Standardization of surgical steps or techniques can decrease error rates, increase efficiency, and ensure reproducible outcomes. In this study, we aimed to analyze the benefit of a standardized approach to robotic partial nephrectomy (RPN) on the reproducibility of outcomes across different tumor complexities. Methods: A single-center study of patients who have undergone a transperitoneal robotic-assisted partial nephrectomy for kidney cancer using the first assistant sparing technique between May 2014 and March 2022 was performed. Overall, 496 patients were included in the analysis. We compared clinical data and perioperative and postoperative outcomes for low, moderate, and high complexity score renal tumors. Tumor complexity was stratified using the Radius, Exophytic/Endophytic, Nearness to the collecting system or sinus, Anterior/Posterior, Location relative to the polar line nephrometry score. Data were compared using Kruskal-Wallis test, Chi-square test of Independence, and Fisher's exact test. Results: Of the patients in the study, 54.64% were low tumor complexities (n = 271), 40.32% were moderate tumor complexities (n = 200), and 5.04% were high tumor complexities (n = 25). High tumor complexity patients had significantly longer operative time (149 minutes versus 137 minutes moderate complexity versus 125 minutes low complexity, P = .001), longer ischemia time (12 minutes versus 11 minutes intermediate versus 10 minutes low complexity, P = .0001), and significant reduction in estimated glomerular filtration rate (-12.58 mL/min/1.73 m2 versus -5.51 mL/min/1.73 m2 intermediate versus -3.08 mL/min/1.73 m2 low complexity, P = .005). There was no significant difference in estimated blood loss (P = .074), blood transfusion rate (P = .454), postoperative complication rate (P = .527), surgical complication rate (P = .210), major complication rate (P = .098), length of hospital stay (P = .583), positive surgical margins (P = .872), and trifecta achievement (P = .740). Conclusion: Irrespective of tumor complexity, approaching RPN using a standardized approach will offer patients favorable perioperative outcomes. This approach has standardized our preoperative counseling, patient expectation, and postoperative surgical pathway across the tumor complexity spectrum.

A Propensity-Matched Comparison of the Perioperative Outcomes Between Single-Port and Multi-Port Robotic Assisted Partial Nephrectomy: A Report from the Single Port Advanced Research Consortium (SPARC).

Purpose: Single-port (SP) robotic surgery is a new technology and early in its adoption curve. The goal of this study is to compare the perioperative outcomes of SP to multi-port (MP) robotic technology for partial nephrectomy. Materials and Methods: This is a prospective cohort study of patients who have undergone robot-assisted partial nephrectomy using SP and MP technology. Baseline demographic, clinical, and tumor-specific characteristics and perioperative outcomes were compared using χ2, t-test, and Mann-Whitney U test in the overall cohort and in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. Results: After propensity matching, 146 SP patients were matched with 146 MP patients. SP and MP groups had similar mean age (58 ± 12 years vs 59 ± 12 years; p = 0.606) and proportion of men (54.11% vs 52.05%; p = 0.725). The SP had a longer mean ischemia (18.29 ± 10.49 minutes vs 13.79 ± 6.29 minutes; p < 0.001). Estimated blood loss (EBL) and length of hospital stay (LOS), operative time, positive margin rate, and any complication rate were similar between the two groups. Conclusions: SP partial nephrectomy had a longer ischemia time, and a comparable LOS, EBL, operative time, positive margin rates, and complication rates to MP. These early data are encouraging. However, the role of SP requires further study and should evaluate safety and long-term data when compared with the standard MP technique.

Single-port Robotic Transvesical Partial Prostatectomy for Localized Prostate Cancer: Initial Series and Description of Technique.

BACKGROUND: Partial prostatectomy has been described as an alternative to focal therapy for the management of localized low- and intermediate-risk prostate cancer. OBJECTIVE: To describe early outcomes and technique for single-port (SP) transvesical partial prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was performed for nine patients with low-volume, localized, low- to intermediate-risk prostate cancer (Gleason ≤7) undergoing SP transvesical partial prostatectomy replicating the inclusion criteria for focal therapy by a single surgeon from November 2020 to March 2022. SURGICAL PROCEDURE: The daVinci SP access port was inserted percutaneously into the bladder and pnuemovesicum was achieved. The camera, robotic instruments, assistant port, and flexible suction tubing were introduced through the access port. The Koelis transrectal ultrasound with preoperative prostate magnetic resonance imaging fusion was used for intraoperative guidance. MEASUREMENTS: Demographic information, intraoperative variables, and postoperative outcomes were collected in an institutional review board-approved database, and a descriptive statistical analysis was performed. RESULTS AND LIMITATIONS: All cases were completed without requiring extra ports or conversion. No intraoperative complications were noted, and all patients were discharged on the day of surgery. Pathology showed Gleason scores of 3 + 3 = 6 in one case, 3 + 4 = 7 in seven cases, and 4 + 3 = 7 in one case, all with negative intraoperative margin assessment. At 6 wk, the median prostate-specific antigen was 0.5 and the median Sexual Health Inventory for Men score was 17.5 from 23 preoperatively. All patients were continent at 6 wk. The limitations include a small number of patients, short follow-up, and single-surgeon experience. CONCLUSIONS: We demonstrated the feasibility of the SP robotic transvesical partial prostatectomy. Early functional outcomes show impressive time to continence and erectile function. Continued follow-up will evaluate long-term oncologic outcomes. PATIENT SUMMARY: We performed partial prostatectomies in selected patients as an alternative to focal therapy using a novel transvesical single-port approach. Our approach was safe and feasible, with fewer complications and promising initial return to continence and erectile function.

Transvesical versus extraperitoneal single-port robotic radical prostatectomy: a matched-pair analysis.

OBJECTIVE: To compare our initial perioperative and postoperative outcomes of the single-port (SP) transvesical radical prostatectomy (TVRP) approach with the single-port extraperitoneal radical prostatectomy (ERP) approach. MATERIALS AND METHODS: Initial consecutive seventy-eight patients underwent SP TVRP between December 2020 and October 2021. Patients with extensive previous abdominal surgeries, or low- to intermediate-risk prostate cancer were selected. Data of consecutive 169 patients treated with SP ERP between February 2019 and November 2020, were used for comparison. Optimal matched-paired analysis of PSA value, biopsy Gleason score, and prostate volume was performed. Preoperative, perioperative, and early functional outcomes were included in the analysis. The median follow-up was 7 months and 9 months for TVRP and ERP groups respectively. RESULTS: The median total operative time was longer in the TVRP compared to the ERP group (p = .002). There were no differences in intraoperative complications or surgical margin status. TVRP group had less rate of grade 3a Clavien-Dindo complications (p = .026). The Foley catheter duration was 3 (3, 4) days in the TVRP group compared to 7 (7, 8) days in the ERP group (p < .001). There was a consistently improved continence rate in the TVRP group at 6 weeks (72% TVRP, 48% ERP, p = .004), 3 months (97% TVRP, 81% ERP, p = .008), and 6 months postoperatively (100% TVRP, 93% ERP, p = .047). There was no difference in biochemical recurrence at 6 months of follow-up. CONCLUSION: In our initial series, TVRP allows for a faster continence recovery, without other functional or oncological compromises.

Redo Robotic Partial Nephrectomy for Recurrent Renal Tumors: A Multi-Institutional Analysis.

Introduction: As the experience with robot-assisted partial nephrectomy (RAPN) grows, the indications have expanded to incorporate previously operated ipsilateral kidneys with recurrent renal masses. We sought to analyze the outcomes of redo RAPN in patients with a recurrent renal mass. Methods: Using a multi-institutional series, the data of 72 patients who underwent RAPN for a recurrent renal mass between 2010 and 2020 were retrospectively analyzed. Patients with familial renal cell carcinoma and multiple renal tumors were excluded. Major complication was defined by Clavien grade ≥3. The median follow-up was 28.5 months. Baseline demographics, clinical and tumor characteristics, and perioperative and postoperative outcomes are reported. Results: Our cohort consisted of a combination of previous thermal ablation (19.6%), laparoscopic (19.6%), open (26.1%), and robotic (34.8%) partial nephrectomy. The median R.E.N.A.L. score was 8. Twenty percent had hilar tumors and 9.7% had a solitary kidney. RAPN was completed in all cases. Two cases (2.8%) were converted to open surgery. None of the cases were converted to radical nephrectomy intraoperatively. One patient underwent radical nephrectomy postoperatively because of bleeding. Transfusion rate was 5.9% and major complication rate was 8.3%. Median length of stay was 3 days. Estimated glomerular filtration rate preservation was 78.7% at discharge and 90.8% at 1-year follow-up. Positive surgical margin rate was 8.3%. Overall, distant recurrence was seen in 11 patients (15.3%), however, only 1 patient had local progression (1.4%). Conclusion: In experienced hands, RAPN is an effective approach to treat select cases of locally recurrent renal masses with promising perioperative and functional outcomes. Patients should be carefully monitored for distant recurrence.

The Multi-Institutional Experience in Single-Port Robotic Transvesical Simple Prostatectomy for Benign Prostatic Hyperplasia Management.

PURPOSE: Single-port (SP) robotic-assisted simple prostatectomy (RASP) through the transvesical approach is a novel surgical option in the management of large prostatic glands. We present the first multi-institutional study to further assess the perioperative and postoperative outcomes of SP RASP. MATERIALS AND METHODS: From February 2019 to November 2021, 91 consecutive patients of 3 separate institutions underwent transvesical RASP using the da Vinci® SP robotic surgical system. Surgeries were performed by 3 experienced surgeons. Through a suprapubic incision and transvesical access, the SP robot is docked directly into the bladder, and the prostatic enucleation is performed. Prospective data collection, including baseline characteristics, perioperative and postoperative outcomes, was performed. The mean followup period was 4.6 months. RESULTS: The mean (SD) prostate volume was 156 (62) ml. The mean (SD) total operative time was 159 (45) minutes, and the median (IQR) estimated blood loss was 100 (50, 200) cc. The median (IQR) postoperative hospital stay was 21.0 (6.5, 26.0) hours; however, 42% of all patients were discharged the same day. The median (IQR) Foley catheter duration was 5 (5, 7) days. Only 3 patients (3%) developed Clavien grade 2 postoperative complications. At 9-month followup, the median (IQR) International Prostate Symptom Score and quality of life score were 4 (2, 5) and 0 (0, 1), respectively, with a mean (SD) maximum flow rate and post-void residual of 21 (17) ml/second and 40 (55) ml, respectively. CONCLUSIONS: In a multi-institutional setting, the SP RASP promotes a pain-free procedure, same-day discharge, short Foley catheter duration, low complication rate and quick recovery.

A Transition Toward a Faster Recovery in Single-Port Transvesical Simple Prostatectomy.

Objectives: To present the updated technique and evaluate the perioperative and postoperative outcomes of single-port transvesical simple prostatectomy (SP TVSP) Patients and Methods: Forty-two consecutive patients with benign prostatic hyperplasia indicated for surgery underwent SP TVSP in a single institution. Through direct suprapubic bladder access, the SP robot was docked. Prostatic enucleation was performed using the prostatic capsule as a landmark. Then a complete vesicourethral mucosal advancement flap was accomplished. Demographics, perioperative, and postoperative data were prospectively collected. Mean follow-up period was 12 months. Results: All procedures were effectively performed with no conversion, additional port placement, or intraoperative complication. The median prostatic volume was 170 cc. Ninety-five percent of the patients did not require opioids analgesia after discharge. Excluding planned admissions, 92% (21/23 patients) were discharged after a median (interquartile range) of 4.6 (4.1-5.7) hours after surgery. The median Foley catheter duration for all cohort was 7 days, and decreased to 3 days after technique adjustment for the last 19 consecutive patients. The median international prostate symptom score decreased from 23 before surgery to 2.5 after surgery. All patients had a significant postoperative improvement in maximum flow rate with a 200% improvement over baseline (19 vs 6.5 mL/sec). Conclusion: In our initial series, SP TVSP allows for favorable perioperative and early postoperative outcomes including low complication same-day discharge, short Foley catheter stay, minimal opioids use, and quick recovery.

The Performance and Optimum Cutoff Value for Pelvic Cavity Index as a Predictor of Early Continence After Extraperitoneal Single-Port Robotic Radical Prostatectomy: Role of Pelvic Anatomical Characteristics.

Purpose: The aim of this study was to assess the value of the pelvic cavity index (PCI), as an objective pelvimetry feature, to predict operative time, margin status, and early urine continence after extraperitoneal single-port robotic radical prostatectomy (RP). We sought to define an optimal cutoff point for PCI in predicting postoperative outcomes. Methods: A total of 94 patients who underwent extraperitoneal single-port robotic RP and preoperative cross-sectional imaging were enrolled. PCI was calculated as follows: Pelvicinletdiameter×PelvicoutletdiameterPelvicdepth. The predictive value of PCI for operative time, surgical margin status, and 3-month urinary continence recovery was assessed using regression models. To report the optimum cutoff value, on receiver operating characteristic (ROC) analysis, we calculated the performance of PCI cutoff points ranging from 5.56 to 10.80 cm by every 0.01 increment. Results: No significant associations were noted between clinical characteristics (including PCI) and operative time. Similarly, other than pathological stage, no clinical variables (including PCI) were predictive of the positive surgical margin. However, a higher PCI was associated with a significantly higher rate of continence 3 months after surgery [odds ratio 2.44 (1.75-5.33); p = 0.01]. On ROC analysis, a PCI cutoff value = 8.21 cm yielded the best accuracy (area under the curve = 0.733, 95% confidence interval 0.615-0.851; p = 0.001). No association was noted between variables and 6-month continence rates. Conclusions: With a single-port robotic system, the operative time, positive surgical margin rate, and long-term continence after prostatectomy would be independent of the bony pelvic cavity. However, a higher PCI is associated with a higher rate of early continence after surgery. PCI at a cutoff of 8.21 cm has the optimum performance to predict postoperative urine continence recovery. If validated, this information may be helpful regarding patient counseling before single-port robotic RP.

Single-port Mini-Pfannenstiel Robotic Pyeloplasty: Establishing a Non-narcotic Pathway Along With a Same-day Discharge Protocol.

OBJECTIVE: To analyze the feasibility of a same day discharge protocol following single-port (SP) robotic pyeloplasty. MATERIALS AND METHODS: From a single institution series, 23 patients (12 multi-port, 11 SP) who underwent primary robotic dismembered pyeloplasty between February 2018 and March 2021 were analyzed. The association between baseline and perioperative characteristics with functional outcome was analyzed using, chi-square, Fisher's exact, Mann Whitney U and t tests. RESULTS: All SP cases were completed using the mini Pfannenstiel incision without the need for conversion or additional ports. Baseline characteristics were comparable. No intraoperative complications were seen. Only 1 patient in the SP group had a Clavien II complication. All patients in the multi-port group had a drain placed, whereas drain was not placed in the SP group. Length of stay was shorter in the SP group (11.4 vs 42.6 hours, P <.001). Although visual analog pain score was comparable at discharge (P = .633), the SP group had lower opioid usage (morphine milligram equivalent) in the hospital (P <.001) and a lower rate of opioid prescription during discharge (18.2% vs 91.7% P <.001). At a median follow-up of 8 months, no patients had flank pain and all patients had good kidney drainage on follow-up images. CONCLUSION: Single-port robotic dismembered pyeloplasty through a mini-Pfannenstiel access allows a same-day discharge protocol with minimal opiate use.

Single-Port Donor Nephrectomy via Modified Pfannenstiel Incision: Initial Preclinical Experience in a Cadaveric Model and Description of Technique.

Objective: To describe the surgical technique for the single-port (SP) transperitoneal donor nephrectomy (DN) through a modified Pfannenstiel incision using the Da Vinci SP® surgical system (Intuitive Surgical, Sunnyvale, CA) on a cadaver. Patients and Methods: In a male cadaver, the SP surgical system was used to perform transperitoneal DN. A 3-cm modified Pfannenstiel incision was made. Through the incision GelPOINT mini (Applied Medical, Rancho Santa Margarita, CA) was inserted. The floating docking technique was used. Through the gel port, the dedicated 25-mm multichannel port and a 12-mm assistant port were introduced. The surgical steps for DN were performed in the following order: (1) mobilization of the colon, (2) identification of psoas muscle, ureter, and the gonadal vein, (3) hilum dissection, (4) perirenal dissection, (5) stapling the renal artery and renal vein, and (6) removal of the kidney through the enlarged incision. Results: Transperitoneal SP DN was completed without any complications or capsulotomy. Additional ports were not needed. The total operative time was 63 minutes and 54 seconds. A good-quality kidney was harvested. Renal artery length was 4 cm. Conclusion: We demonstrated the feasibility of SP transperitoneal DN through modified Pfannenstiel incision, using the novel SP robotic platform. Further assessment is necessary in a clinical setting.

Unified model involving genomics, magnetic resonance imaging and prostate-specific antigen density outperforms individual co-variables at predicting biopsy upgrading in patients on active surveillance for low risk prostate cancer.

BACKGROUND: Active surveillance (AS) is the reference standard treatment for the management of low risk prostate cancer (PCa). Accurate assessment of tumor aggressiveness guides recruitment to AS programs to avoid conservative treatment of intermediate and higher risk patients. Nevertheless, underestimating the disease risk may occur in some patients recruited, with biopsy upgrading and the concomitant potential for delayed treatment. AIM: To evaluate the accuracy of mpMRI and GPS for the prediction of biopsy upgrading during active surveillance (AS) management of prostate cancer (PCa). METHOD: A retrospective analysis was performed on 144 patients recruited to AS from October 2013 to December 2020. Median follow was 4.8 (IQR 3.6, 6.3) years. Upgrading was defined as upgrading to biopsy grade group ≥2 on follow up biopsies. Cox proportional hazard regression was used to investigate the effect of PSA density (PSAD), baseline Prostate Imaging-Reporting and Data System (PI-RADS) v2.1 score and GPS on upgrading. Time-to-event outcome, defined as upgrading, was estimated using the Kaplan-Meier method with log-rank test. RESULTS: Overall rate of upgrading was 31.9% (n = 46). PSAD was higher in the patients who were upgraded (0.12 vs. 0.08 ng/ml2 , p = .005), while no significant difference was present for median GPS in the overall cohort (overall median GPS 21; 22 upgrading vs. 20 no upgrading, p = .2044). On univariable cox proportional hazard regression analysis, the factors associated with increased risk of biopsy upgrading were PSA (HR = 1.30, CI 1.16-1.47, p = <.0001), PSAD (HR = 1.08, CI 1.05-1.12, p = <.0001) and higher PI-RADS score (HR = 3.51, CI 1.56-7.91, p = .0024). On multivariable cox proportional hazard regression analysis, only PSAD (HR = 1.10, CI 1.06-1.14, p = <.001) and high PI-RADS score (HR = 4.11, CI 1.79-9.44, p = .0009) were associated with upgrading. A cox regression model combining these three clinical features (PSAD ≥0.15 ng/ml2 at baseline, PI-RADS Score and GPS) yielded a concordance index of 0.71 for the prediction of upgrading. CONCLUSION: In this study PSAD has higher accuracy over baseline PI-RADS score and GPS score for the prediction of PCa upgrading during AS. However, combined use of PSAD, GPS and PI-RADS Score yielded the highest predictive ability with a concordance index of 0.71.