A new compressed sensing cine cardiac MRI sequence with free-breathing real-time acquisition and fully automated motion-correction: A comprehensive evaluation.

PURPOSE: The purpose of this study was to compare a new free-breathing compressed sensing cine (FB-CS) cardiac magnetic resonance imaging (CMR) to the standard reference multi-breath-hold segmented cine (BH-SEG) CMR in an unselected population. MATERIALS AND METHODS: From January to April 2021, 52 consecutive adult patients who underwent both conventional BH-SEG CMR and new FB-CS CMR with fully automated respiratory motion correction were retrospectively enrolled. There were 29 men and 23 women with a mean age of 57.7 ± 18.9 (standard deviation [SD]) years (age range: 19.0-90.0 years) and a mean cardiac rate of 74.6 ± 17.9 (SD) bpm. For each patient, short-axis stacks were acquired with similar parameters providing a spatial resolution of 1.8 × 1.8 × 8.0 mm3 and 25 cardiac frames. Acquisition and reconstruction times, image quality (Likert scale from 1 to 4), left and right ventricular volumes and ejection fractions, left ventricular mass, and global circumferential strain were assessed for each sequence. RESULTS: FB-CS CMR acquisition time was significantly shorter (123.8 ± 28.4 [SD] s vs. 267.2 ± 39.3 [SD] s for BH-SEG CMR; P < 0.0001) at the penalty of a longer reconstruction time (271.4 ± 68.7 [SD] s vs. 9.9 ± 2.1 [SD] s for BH-SEG CMR; P < 0.0001). In patients without arrhythmia or dyspnea, FB-CS CMR provided subjective image quality that was not different from that of BH-SEG CMR (P = 0.13). FB-CS CMR improved image quality in patients with arrhythmia (n = 18; P = 0.002) or dyspnea (n = 7; P = 0.02), and the edge sharpness was improved at end-systole and end-diastole (P = 0.0001). No differences were observed between the two techniques in ventricular volumes and ejection fractions, left ventricular mass or global circumferential strain in patients in sinus rhythm or with cardiac arrhythmia. CONCLUSION: This new FB-CS CMR addresses respiratory motion and arrhythmia-related artifacts without compromising the reliability of ventricular functional assessment.

International Natural Procreative Technology Evaluation and Surveillance of Treatment for Subfertility (iNEST): enrollment and methods.

STUDY QUESTION: What is the feasibility of a prospective protocol to follow subfertile couples being treated with natural procreative technology for up to 3 years at multiple clinical sites? SUMMARY ANSWER: Overall, clinical sites had missing data for about one-third of participants, the proportion of participants responding to follow-up questionnaires during time periods when participant compensation was available (about two-thirds) was double that of time periods when participant compensation was not available (about one-third) and follow-up information was most complete for pregnancies and births (obtained from both clinics and participants). WHAT IS KNOWN ALREADY: Several retrospective single-clinic studies from Canada, Ireland and the USA, with subfertile couples receiving restorative reproductive medicine, mostly natural procreative technology, have reported adjusted cumulative live birth rates ranging from 29% to 66%, for treatment for up to 2 years, with a mean women's age of about 35 years. STUDY DESIGN SIZE DURATION: The international Natural Procreative Technology Evaluation and Surveillance of Treatment for Subfertility (iNEST) was designed as a multicenter, prospective cohort study, to enroll subfertile couples seeking treatment for live birth, assess baseline characteristics and follow them up for up to 3 years to report diagnoses, treatments and outcomes of pregnancy and live birth. In addition to obtaining data from medical record abstraction, we sent follow-up questionnaires to participants (both women and men) to obtain information about treatments and pregnancy outcomes, including whether they obtained treatment elsewhere. The study was conducted from 2006 to 2016, with a total of 10 clinics participating for at least some of the study period across four countries (Canada, Poland, UK and USA). PARTICIPANTS/MATERIALS SETTING METHODS: The 834 participants were subfertile couples with the woman's age 18 years or more, not pregnant and seeking a live birth, with at least one clinic visit. Couples with known absolute infertility were excluded (i.e. bilateral tubal blockage, azoospermia). Most women were trained to use a standardized protocol for daily vulvar observation, description and recording of cervical mucus and vaginal bleeding (the Creighton Model FertilityCare System). Couples received medical and sometimes surgical evaluation and treatments aimed to restore and optimize female and male reproductive function, to facilitate in vivo conception. MAIN RESULTS AND THE ROLE OF CHANCE: The mean age of women starting treatment was 34.0 years; among those with additional demographic data, 382/478 (80%) had 16 or more years of education, and 199/659 (30%) had a prior live birth. Across 10 clinical sites in four countries (mostly private clinical practices) with family physicians or obstetrician-gynecologists, data about clinic visits were submitted for 60% of participants, and diagnostic data for 77%. For data obtained directly from the couple, 59% of couples had at least one follow-up questionnaire, and the proportion of women and men responding to fill out the follow-up questionnaires was 69% and 67%, respectively, when participant financial compensation was available, compared to 38% and 33% when compensation was not available. Among all couples, 57% had at least one pregnancy and 44% at least one live birth during the follow-up time period, based on data obtained from clinic and/or participant questionnaires. All sites reported on female pelvic surgical procedures, and among all participants, 22% of females underwent a pelvic diagnostic and/or therapeutic procedure, predominantly laparoscopy and hysterosalpingography. Among the 643 (77%) of participants with diagnostic information, ovulation-related disorders were diagnosed in 87%, endometriosis in 31%, nutritional disorders in 47% and abnormalities of semen analysis in 24%. The mean number of diagnoses per couple was 4.7. LIMITATIONS REASONS FOR CAUTION: The level of missing data was higher than anticipated, which limits both generalizability and the ability to study different components of treatment and prognosis. Loss to follow-up may also be differential and introduce bias for outcomes. Most of the participating clinicians were not surgeons, which limits the opportunity to study the impact of surgical interventions. Participants were geographically dispersed but relatively homogeneous with regard to socioeconomic status, which may limit the generalizability of current and future findings. WIDER IMPLICATIONS OF THE FINDINGS: Multicenter studies are key to understanding the outcomes of subfertility treatments beyond IVF or IUI in broader populations, and the association of different prognostic factors with outcomes. We anticipate that the iNEST study will provide insight for clinical and treatment factors associated with outcomes of pregnancy and live birth, with appropriate attention to potential biases (including adjustment for potential confounders, multiple imputation for missing data, sensitivity analysis and inverse probability weighting for potential differential loss to follow-up, and assessments for clinical site heterogeneity). Future studies will need to either have: adequate funding to compensate clinics and participants for robust data collection, including targeted randomized trials; or a scaled-down, registry-based approach with targeted data points, similar to the multiple national and regional ART registries. STUDY FUNDING/COMPETING INTERESTS: Funding for the study came from the International Institute for Restorative Reproductive Medicine, the University of Utah, Department of Family and Preventive Medicine, Health Studies Fund, the Primary Children's Medical Foundation, the Mary Cross Tippmann Foundation, the Atlas Foundation, the St. Augustine Foundation and the Women's Reproductive Health Foundation. The authors declare no competing interests. TRIAL REGISTRATION NUMBER: The iNEST study is registered at clinicaltrials.gov, NCT01363596.

Restorative reproductive medicine for infertility in two family medicine clinics in New England, an observational study.

BACKGROUND: Restorative reproductive medicine (RRM) seeks to identify and correct underlying causes and factors contributing to infertility and reproductive dysfunction. Many components of RRM are highly suitable for primary care practice. We studied the outcomes amongst couples who received restorative reproductive medicine treatment for infertility in a primary care setting. METHODS: Two family physicians in Massachusetts trained in a systematic approach to RRM (natural procreative technology, or NaProTechnology) treated couples with infertility. We retrospectively reviewed the characteristics, diagnoses, treatments, and outcomes for all couples treated during the years 1989 to 2014. We compared pregnancy and live birth by clinical characteristics using Kaplan-Meier analysis. We employed the Fleming-Harrington weighted Renyi test or the logrank test to compare the cumulative proportion with pregnancy or with live birth. RESULTS: Among 370 couples beginning treatment for infertility, the mean age was 34.8 years, the mean prior time trying to conceive was 2.7 years, and 27% had a prior live birth. The mean number of diagnoses per couple was 4.9. Treatment components included fertility tracking with the Creighton Model FertilityCare System (80%); medications to enhance cervical mucus production (81%), to stimulate ovulation (62%), or to support the luteal phase (75%); and referral to female laparoscopy by a surgeon specializing in endometriosis (46%). The cumulative live birth rate at 2 years was 29% overall; this was significantly higher for women under age 35 (34%), and for women with body mass index < 25 (40%). There were 2 sets of twins and no higher-order multiple gestations. Of the 63 births with data available, 58 (92%) occurred at term. CONCLUSIONS: Family physicians can provide a RRM approach for infertility to identify underlying causes and promote healthy term live births. Younger women and women with body mass index < 25 are more likely to have a live birth.

Identification and characterization of peripheral vascular color-coded DECT lesions in gout and non-gout patients: The VASCURATE study.

OBJECTIVE: To characterize peripheral vascular plaques color-coded as monosodium urate (MSU) deposition by dual-energy computed tomography (DECT) and assess their association with the overall soft-tissue MSU crystal burden. METHODS: Patients with suspected crystal arthropathies were prospectively included in the CRYSTALILLE inception cohort to undergo baseline knees and ankles/feet DECT scans; treatment-naive gout patients initiating treat-to-target urate-lowering therapy (ULT) underwent repeated DECT scans with concomitant serum urate level measurements at 6 and 12 months. We determined the prevalence of DECT-based vascular MSU-coded plaques in knee arteries, and assessed their association with the overall DECT volumes of soft-tissue MSU crystal deposition and coexistence of arterial calcifications. DECT attenuation parameters of vascular MSU-coded plaques were compared with dense calcified plaques, control vessels, control soft tissues, and tophi. RESULTS: We investigated 126 gout patients and 26 controls; 17 ULT-naive gout patients were included in the follow-up study. The prevalence of DECT-based vascular MSU-coded plaques was comparable in gout patients (24.6%) and controls (23.1%; p=0.87). Vascular MSU-coded plaques were strongly associated with coexisting arterial calcifications (p<0.001), but not with soft-tissue MSU deposition. Characterization of vascular MSU-coded plaques revealed specific differences in DECT parameters compared with control vessels, control soft tissues, and tophi. During follow-up, vascular MSU-coded plaques remained stable despite effective ULT (p=0.64), which decreased both serum urate levels and soft-tissue MSU volumes (p<0.001). CONCLUSION: Our findings suggest that DECT-based MSU-coded plaques in peripheral arteries are strongly associated with calcifications and may not reflect genuine MSU crystal deposition. Such findings should therefore not be a primary target when managing gout patients.

The Impact of Previous Prostate Surgery on Surgical Outcomes for Patients Treated with Robot-assisted Radical Cystectomy for Bladder Cancer.

BACKGROUND: The feasibility and safety of robot-assisted radical cystectomy (RARC) may be undermined by unfavorable preoperative surgical characteristics such as previous prostate surgery (PPS). OBJECTIVE: To compare perioperative outcomes for patients undergoing RARC with versus without a history of PPS. DESIGN, SETTING, AND PARTICIPANTS: The study included 220 consecutive patients treated with RARC and pelvic lymph node dissection for bladder cancer at a single European tertiary centre. Of these, 43 had previously undergone PPS, defined as transurethral resection of the prostate/holmium laser enucleation of the prostate (n=21) or robot-assisted radical prostatectomy (n=22). SURGICAL PROCEDURE: RARC in patients with a history of PPS. MEASUREMENTS: Data on postoperative complications were collected according to the quality criteria for accurate and comprehensive reporting of surgical outcomes recommended by the European Association of Urology guidelines. Multivariable logistic, linear, and Poisson regression analyses were performed to test the effect of PPS on surgical outcomes. RESULTS AND LIMITATIONS: Overall, 43 patients (20%) were treated with RARC after PPS. Operative time (OT) was longer in the PPS group (360 vs 330min; p<0.001). Patients with PPS experienced higher rates of intraoperative complications (19% vs 6.8%) and higher rates of 30-d (67% vs 39%), and Clavien-Dindo >3 (33% vs 16%) postoperative complications (all p<0.05). Moreover, the positive surgical margin (PSM) rate after RARC was higher in the PPS group (14% vs 4%; p=0.03). On multivariable analyses, PPS at RARC independently predicted higher risk of intraoperative (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.04-6.21; p=0.01) and 30-d complications (OR 2.26, 95% CI 1.05-5.22; p=0.02), as well as longer OT (relative risk [RR] 1.03, 95% CI 1.00-1.05; p=0.02) and length of stay (RR 1.13, 95% CI 1.02-1.26; p=0.02). Lack of randomization represents the main limitation. CONCLUSIONS: RARC in patients with a history of PPS is feasible, but it is associated with a higher risk of complications and longer OT and length of stay. Moreover, higher PSM rates have been reported for these patients. Thus, measures aimed at improving surgical outcomes appear to be warranted. PATIENT SUMMARY: We investigated the effect of previous prostate surgery (PPS) on surgical outcomes after robot-assisted removal of the bladder. We found that patients with PPS have a higher risk of complications and longer hospitalization after bladder removal. These patients deserve closer evaluation before this type of bladder operation.

Marital Satisfaction of Infertile Couples Using Natural Procreative Technology (NaProTECHNOLOGY).

ABSTRACT: Infertility affects one in 16 married women in the United States where 12.7% of these seek treatment. The stress of infertility and treatment is known to impact marital satisfaction, which can be further complicated by personal and religious beliefs regarding the ethics of some assistive reproductive technologies. A morally acceptable approach to infertility diagnosis and treatment is natural procreative technology or NaProTECHNOLOGY (NPT) using the Creighton Model FertilityCare™ System. A quantitative, descriptive study utilizing demographic surveys and the Index of Marital Satisfaction found that couples using NPT reported marital satisfaction.

Robot-Assisted Radical Cystectomy for Bladder Cancer in Octogenarians.

OBJECTIVE: To evaluate perioperative morbidity and mortality rate, a 3-year recurrence-free survival, and cancer-specific mortality rate in patients older than 80 years undergoing robot-assisted radical cystectomy (RARC). MATERIALS AND METHODS: We retrospectively collected data of 155 consecutive patients who received RARC for muscle-invasive or high-risk nonmuscle-invasive urothelial carcinoma of the bladder between 2003 and 2014 at a high-volume robotic center. Diversion was performed intra- or extracorporeally according to the surgeon's preferences. Complications were graded according to the Clavien-Dindo system. Logistic regression analyses were used to assess the impact of age on postoperative outcomes. RESULTS: Of 155 consecutive patients, 22 (14.2%) patients were 80 years or older. Octogenarians did not significantly differ from younger patients in ASA score (p = 0.4) and Charlson comorbidity index (p = 0.4). Prevalence of any grade and high-grade complications was similar in both groups (all p ≥ 0.6). Older patients had a significantly higher pathologic tumor grade (p = 0.04) and a lower use of pelvic lymphadenectomy (p < 0.001). No perioperative mortality rate was recorded within 90 days from surgery. Elderly patients had a similar risk of 3-year oncologic recurrence after surgery compared with their younger counterparts (odds ratio [OR] 1.63; p = 0.2). Conversely, the risk of cancer-specific mortality rate was significantly higher (OR 2.78; p = 0.02). CONCLUSIONS: Patients 80 years or older undergoing RARC for bladder cancer did not have a higher risk of peri- and postoperative morbidity and mortality rate and had a similar 3-year recurrence-free survival, suggesting that RARC can be safely performed in selected elderly patients by experienced surgeons.

Port site metastasis in prostate cancer.

Port-site metastasis of prostatic adenocarcinoma is rare and usually associated with poor prognosis. We report a case of a young man with a rising prostate-specific antigen (PSA) 4.5 years after robot-assisted laparoscopic prostatectomy (RALP) and extended pelvic lymphadenectomy (ePLND) for a Gleason 7 (4+3) prostate cancer (pT3b pN0 cM0). Choline positron emission tomography-computed tomography (PET-CT) demonstrated a PET positive subcutaneous recurrence in a previous trocar site accompanied by a PET positive ipsilateral inguinal lymph node. Excision of both lesions was performed, confirming the diagnosis of metastatic prostate cancer. The patient's PSA dropped significantly postoperatively enabling postponement of androgen deprivation treatment up to this date. The etiology of port-site metastasis is multifactorial, including patient and surgery related factors. Such metastases have been scarcely reported following ePLND with or without RALP. Certain surgical precautions can be made to prevent the occurrence. We summarize previously reported mechanisms of development and possible precautionary measures.

Long-term evaluation of survival, continence and potency (SCP) outcomes after robot-assisted radical prostatectomy (RARP).

OBJECTIVE: To report combined oncological and functional outcome in a series of patients who underwent robot-assisted radical prostatectomy (RARP) for clinically localised prostate cancer in a single European centre after 5-year minimum follow-up according to survival, continence and potency (SCP) outcomes. PATIENTS AND METHODS: We extracted from our prostate cancer database all consecutive patients with a minimum follow-up of 5 years after RARP. Biochemical failure was defined as a confirmed PSA concentration of >0.2 ng/mL. All patients alive at the last follow-up were evaluated for functional outcomes using the Expanded Prostate Cancer Index Composite (EPIC) and Sexual Health Inventory for Men (SHIM) questionnaires. Oncological and functional outcomes were reported according to the SCP system. Specifically, patients were classified as using no pad (C0), using one pad for security (C1), and using ≥1 pad (C2) (not including the prior definition). Patients potent (SHIM score of >17) without any aids were classified as P0 category; patients potent (SHIM score of >17) with use of phosphodiesterase type 5 inhibitorsas P1; and patients with erectile dysfunction (SHIM score of <17) as P2 category. Patients who did not undergo a nerve-sparing technique, who were not potent preoperatively, who were not interested in erections, or who did not have sexual partners were classified as Px category. RESULTS: The 3-, 5- and 7-year biochemical recurrence-free survival rates were 96.3%; 89.6% and 88.3%, respectively. At follow-up, 146 (79.8%) were fully continent (C0), 20 (10.9%) still used a safety pad (C1) and 17 (9.3%) were incontinent using ≥1 pad (C2). Excluding Px patients, 52 patients (47.3%) were classified as P0; 41 patients (37.3%) were classified as P1 and 17 patients (15.5%) were P2. In patients preoperatively continent and potent, who received a nerve-sparing technique and did not require any adjuvant therapy, oncological and functional success was attained by 77 (80.2%) patients. In the subgroup of 67 patients not evaluable for potency recovery (Px), oncological and continence outcomes were attained in 46 patients (68.7%). CONCLUSIONS: Oncological and functional success was attained in a high percentage of patients who underwent RARP at ≥5 years follow-up. Interestingly, this study confirmed that excellent oncological and functional outcomes can be obtained in the 'best' category of patients, i.e. those preoperatively continent and potent and with tumour characteristics suitable for a nerve-sparing technique.

Long-term biochemical recurrence rates after robot-assisted radical prostatectomy: analysis of a single-center series of patients with a minimum follow-up of 5 years.

OBJECTIVE: To address the long-term biochemical recurrence (BCR)-free survival rates of patients treated with robotic-assisted laparoscopic prostatectomy (RALP) with a minimum follow-up of 5 years. MATERIALS AND METHODS: Prospectively collected data of 184 patients treated with RALP at a single institution were analyzed. Kaplan-Meier and life tables analyses targeted the rates of BCR according to pathologic parameters. Cox regression analyses addressed predictors of BCR. RESULTS: Median follow-up was 67.5 months. One and 10 patients died of prostate cancer (PCa) and other causes, respectively. Mean time to BCR was 83.8 months. The 3-, 5-, and 7-year BCR-free survival rates were 94%, 86%, and 81%, respectively. These rates were 97%, 93%, and 85% for pT2 disease; 94%, 84%, and 84% for pT3a; and 69%, 43%, and 43% for pT3b (P<.001). The same figures were 97%, 90%, and 88% for Gleason sum 6 or lower; 90%, 86%, and 75% for Gleason sum 7; and 85%, 65%, and 65% for Gleason sum 8-10 (P=.01). At univariable analyses, prostate-specific antigen, pathologic Gleason score, and presence of extracapsular extension, seminal vesicle invasion, and adjuvant radiotherapy were significantly associated with BCR. At multivariable analysis, the presence of seminal vesicle invasion and the presence of Gleason sum 8-10 represented independent predictors of BCR (HR=5.14; P=.004 and HR=3.04; P=.04, respectively). CONCLUSION: We report the longest available follow-up in RALP patients. RALP represents an oncologically effective procedure. Our oncological results support the increasing diffusion of RALP for the treatment of organ-confined PCa.

Total intracorporeal robot-assisted laparoscopic ileal conduit (Bricker) urinary diversion: technique and outcomes.

OBJECTIVE: Several recent preliminary reports have demonstrated that Robot-Assisted Cystectomy with total intracorporeal Ileal Conduit (RACIC) is a feasible option over the open technique. We report our stepwise surgical procedure of robotic total intracorporeal ileal conduit urinary diversion, technical consideration, development, refinements and initial experience. Only the ileal conduit urinary diversion is described with no emphasis on the cystectomy's steps. METHODS: Between February 2008 and September 2009, nine patients underwent RACIC for muscle invasive transitional cell carcinoma (TCC). The entire procedure, including radical cystoprostatectomy, extended pelvic node dissection (ePLND), ileal conduit urinary diversion (Bricker) including isolation of the ileal loop (20 cm ileal segment) 15 cm away from the ileocecal junction, restoration of bowel continuity with stapled side-to-side ileo-ileal anastomosis, retroperitoneal transfer of the left ureter to the right side, and bilateral stented (8 F feeding tube) ileo-ureteral anastomoses in a Wallace faction were all performed exclusively intracorporeally using the da Vinci Si surgical robot and finally the conduit stoma was fashioned. RESULTS: The RACIC was technically successful in all nine patients (three females and six males. Mean age 74.1; 57 to 87) without open conversion. The mean operative time including extended pelvic lymphadenectomy and urinary diversion was 346.2 minutes (210 to 480). Mean operative time of diversion is 72 minutes (52-113) mean estimated blood loss 258 mL (200 to 500) and the median hospital stay were 14 days (10 to 27). In all three female patients, the specimen was extracted through the vagina. There were no intraoperative complications and only one major postoperative complication: one postoperative iatrogenous necrosis of the ileal conduit caused by uncareful retraction of the organ bag and thereby probably injuring the conduit pedicle, as the ileal conduit was well vascularised at the end of the operation, requiring an open revision (in male patient extracted through the suprapubic incision). A clear liquid diet was started on the third postoperative day. All patients returned to normal activity within 2 weeks (from date of surgery). Postoperative renal function was normal with mean postoperative creatine 0.99 mg/dL) and excretory urography revealed unobstructed upper tracts in all cases. CONCLUSION: Robot-assisted radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion for the treatment of high risk or invasive bladder cancer with urinary diversion is technically feasible. The robotic system aids in performing a meticulous dissection and all operative steps of the open procedure are replicated precisely while adhering to the sound oncologic principles of traditional radical cystectomy. Robotics brings an unprecedented control of surgical instruments, shorten the learning curve, and allow open surgeons to apply more easily their technical skill in a minimal invasive fashion. Robotic cystectomy with total intracorporeal ileal conduit urinary diversion offers operative and perioperative benefits and functional outcome. In our hands results comparable to open experience with further reduced perioperative morbidity, early recovery, resumption of normal activities, excellent cosmesis and increased quality of life (QOL). In addition, minimal blood loss, fluid shifts, and electrolyte loss considerably reduce systemic and cardiovascular stress in these older groups of patients.

Lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

OBJECTIVE: To evaluate the incidence of, and predictors for, lymphadenectomy in patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer. PATIENTS AND METHODS: Utilizing the International Robotic Cystectomy Consortium (IRCC) database, 527 patients were identified who underwent RARC at 15 institutions from 2003 to 2009. After stratification by age group, sex, pathological T stage, nodal status, sequential case number, institutional volume and surgeon volume, logistic regression was used to correlate variables to the likelihood of undergoing lymphadenectomy (defined as ≥ 10 nodes removed). RESULTS: Of the 527 patients, 437 (82.9%) underwent lymphadenectomy. A mean of 17.8 (range 0-68) lymph nodes were examined. Tumour stage, sequential case number, institution volume and surgeon volume were significantly associated with the likelihood of undergoing lymphadenectomy. Surgeon volume was most significantly associated with lymphadenectomy on multivariate analysis. High-volume surgeons (> 20 cases) were almost three times more likely to perform lymphadenectomy than lower-volume surgeons, all other variables being constant [odds ratio (OR) = 2.37; 95% confidence interval (CI) = 1.39-4.05; P = 0.002]. CONCLUSION: The rates of lymphadenectomy at RARC for advanced bladder cancer are similar to those of open cystectomy series using a large, multi-institutional cohort. There does, however, appear to be a learning curve associated with the performance of lymphadenectomy at RARC.

Does previous robot-assisted radical prostatectomy experience affect outcomes at robot-assisted radical cystectomy? Results from the International Robotic Cystectomy Consortium.

OBJECTIVES: To evaluate the effect of previous robot-assisted radical prostatectomy (RARP) case volume on the outcomes of robot-assisted radical cystectomy. Little is known regarding the effect of previous robotic surgical experience on the implementation and execution of robot-assisted radical cystectomy. METHODS: Using the International Robotic Cystectomy Consortium database, 496 patients were identified who had undergone robot-assisted radical cystectomy by 21 surgeons at 14 institutions from 2003 to 2009. The surgeons were divided into 4 groups according to their previous RARP experience (≤ 50, 51-100, 101-150, and > 150 cases). The overall operative time, blood loss, lymph node yield, pathologic stage, and surgical margin status were compared among the 4 groups using chi-square analysis. RESULTS: The mean operative time was 386 minutes (range 178-827). The mean estimated blood loss was 408 mL (range 25-3500). The operative time and blood loss were both significantly associated with previous RARP experience (P < .001). The mean lymph node count was 17.8 nodes (range 0-68). Lymph node yield and increased pathologic stage were significantly associated with previous RARP experience (P < .001). Finally, 34 (7.0%) of the 482 patients had a positive surgical margin. Margin status was not significantly associated with previous RARP experience (P = .089). CONCLUSIONS: Previous RARP case volume might affect the operative time, blood loss, and lymph node yield at robot-assisted radical cystectomy. In addition, surgeons with increased RARP experience operated on patients with more advanced tumors. Previous RARP experience, however, did not appear to affect the surgical margin status.

The learning curve of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

BACKGROUND: Robot-assisted radical cystectomy (RARC) has evolved as a minimally invasive alternative to open radical cystectomy for patients with invasive bladder cancer. OBJECTIVE: We sought to define the learning curve for RARC by evaluating results from a multicenter, contemporary, consecutive series of patients who underwent this procedure. DESIGN, SETTING, AND PARTICIPANTS: Utilizing the International Robotic Cystectomy Consortium database, a prospectively maintained and institutional review board-approved database, we identified 496 patients who underwent RARC by 21 surgeons at 14 institutions from 2003 to 2009. MEASUREMENTS: Cut-off points for operative time, lymph node yield (LNY), estimated blood loss (EBL), and margin positivity were identified. Using specifically designed statistical mixed models, we were able to inversely predict the number of patients required for an institution to reach the predetermined cut-off points. RESULTS AND LIMITATIONS: Mean operative time was 386 min, mean EBL was 408 ml, and mean LNY was 18. Overall, 34 of 482 patients (7%) had a positive surgical margin (PSM). Using statistical models, it was estimated that 21 patients were required for operative time to reach 6.5h and 8, 20, and 30 patients were required to reach an LNY of 12, 16, and 20, respectively. For all patients, PSM rates of <5% were achieved after 30 patients. For patients with pathologic stage higher than T2, PSM rates of <15% were achieved after 24 patients. CONCLUSIONS: RARC is a challenging procedure but is a technique that is reproducible throughout multiple centers. This report helps to define the learning curve for RARC and demonstrates an acceptable level of proficiency by the 30th case for proxy measures of RARC quality.

Surgical margin status after robot assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

PURPOSE: Positive surgical margins at radical cystectomy confer a poor prognosis. We evaluated the incidence and predictors of positive surgical margins in patients who underwent robot assisted radical cystectomy for bladder cancer. MATERIALS AND METHODS: Using the International Robotic Cystectomy Consortium database we identified 513 patients who underwent robot assisted radical cystectomy, as done by a total of 22 surgeons at 15 institutions from 2003 to 2009. After stratification by age group, gender, pathological T stage, nodal status, sequential case number and institutional volume logistic regression was used to correlate variables with the likelihood of a positive surgical margin. RESULTS: Of the 513 patients 35 (6.8%) had a positive surgical margin. Increasing 10-year age group, lymph node positivity and higher pathological T stage were significantly associated with an increased likelihood of a positive margin (p = 0.010, <0.001 and p <0.001, respectively). Gender, sequential case number and institutional volume were not significantly associated with margin positivity. The rate of margin positive disease at cystectomy was 1.5% for pT2 or less, 8.8% for pT3 and 39% for pT4 disease. CONCLUSIONS: Positive surgical margin rates at robot assisted radical cystectomy for advanced bladder cancer were similar to those in open cystectomy series in a large, multi-institutional, prospective cohort. Sequential case number, a surrogate for the learning curve and institutional volume were not significantly associated with positive margins at robot assisted radical cystectomy.

Impact of the learning curve on perioperative outcomes in patients who underwent robotic partial nephrectomy for parenchymal renal tumours.

BACKGROUND: Robot-assisted partial nephrectomy (RAPN) is an emerging, minimally invasive technique to treat patients with small renal masses. OBJECTIVE: To evaluate the impact of the learning curve on perioperative outcomes such as operative times and warm ischaemia times (WIT), blood loss, overall complications, and renal function impairment in patients who underwent RAPN. DESIGN, SETTING, AND PARTICIPANTS: We collected prospectively the clinical and pathologic records of 62 consecutive patients who underwent RAPN between September 2006 and November 2009 for renal tumours at a nonacademic teaching institution by a single surgeon with extensive prior robotic experience. INTERVENTIONS: The surgeon used transperitoneal RAPN with excision of an adequate rim of healthy peritumour renal parenchyma. MEASUREMENTS: Perioperative parameters, pathologic outcome, and short-term outcomes for renal function were recorded. The effects of the learning curve on the previous reported perioperative and functional outcomes was studied. RESULTS AND LIMITATIONS: The mean pathologic tumour size was 2.8 +/-1.3 cm. A pelvicaliceal repair was needed in 33 cases (53%). The mean console time was 91 +/-33 min (range: 52-180), with a mean WIT of 20 +/- 7 min (range: 9-40). Warm ischaemia (<20 min) and console times were optimised after the first 30 (p<0.001) and 20 cases (p<0.001), respectively. Pathologic results yielded a positive surgical margin (PSM) rate of 2%. Mean creatinine level changed from a baseline value of 1.02 +/- 0.38 mg/dl to 1.1 +/- 0.7 mg/dl 3 mo after surgery. Estimated glomerular filtration rate changed from a baseline value of 81.17 +/- 29 to 80.5 +/- 29 (millilitres per minute per 1.73 m(2)) 3 mo postoperatively. CONCLUSIONS: RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. Specifically, in the hands of a surgeon with extensive robotic experience, RAPN requires a short learning curve to reach WIT < 20 min, console times < 100 min, limited blood loss, and acceptable overall complication rates.