Implementation of single-port robotic urologic surgery: experience at a large academic center.

The Single-Port (SP) robotic system is increasingly being implemented in the United States, allowing for several minimally invasive urologic procedures to be performed. The present study aims to describe our single-center experience since the adoption of the SP platform. We retrospectively collected and analyzed consecutive SP cases performed at a major teaching hospital in the Midwest (Rush University Medical Center) from December 2020 to December 2023. Demographic variables were collected. Surgical and pathological outcomes were analyzed in the overall cohort and for each type of procedure. The study timeframe was divided into two periods to assess the evolution of SP technical features over time. In total, 160 procedures were performed, with robot-assisted radical prostatectomy (RARP) being the most common (49.4%). Overall, 54.4% of the procedures were extraperitoneal, with a significantly higher adoption of this approach in the second half of the study period (30% vs 74.3%, p < 0.001). A "plus one" assistant port was adopted in 38.1% of cases, with a shift towards a "pure" single-port surgery in the most recent procedures (21.1% vs 76.7%, p < 0.001). The median LOS was 33.5 h (30-48), with a rate of any grade and CD ≥ 3 postoperative complications of 9.4% and 2.5%, respectively, and a 30-day readmission rate of 1.9%. SP robotic surgery can be safely and effectively implemented for various urologic procedures. With increasing experience, the SP platform allows shifting away from transperitoneal procedures, potentially minimizing postoperative pain, and shortening hospital stay and postoperative recovery.

Correction: Predictors of fluoroquinolone-resistant bacteria in the rectal vault of men undergoing prostate biopsy.

The original version of this article contained an error in the name of author Alfredo Mena Lora. This has now been corrected.

Predictors of fluoroquinolone-resistant bacteria in the rectal vault of men undergoing prostate biopsy.

IMPORTANCE: Fluoroquinolone (FQ)-resistant rectal vault flora is associated with infectious complications in men undergoing transrectal ultrasound-guided prostate needle biopsy (TRUS-PNB). OBJECTIVE: To determine the patient factors that predict FQ-resistant rectal cultures in men who are undergoing transrectal ultrasound-guided prostate needle biopsy. METHODS: An IRB approved retrospective review of 6183 consecutive men who had undergone a rectal swab culture in preparation for TRUS-PNB between January 2013 and December 2014 was performed. Multivariable logistic regression was used to determine the clinical and demographic factors associated with FQ-resistant Enterobacteriaceae in the rectal vault. RESULTS: Of the 6179 rectal swabs analyzed, 4842 (78%) were FQ-sensitive, and 1337 (22%) were FQ-resistant. On univariable analysis, increasing age, prior TRUS-PNB, higher number of biopsy cores obtained, diabetes mellitus, antimicrobial use within the past 6 months and non-Caucasian race were predictors of FQ-resistance (all p < 0.05). Men with FQ-resistant cultures were more likely to have benign pathology on TRUS-PNB (p = 0.004). On multivariable analysis, increasing patient age (OR = 1.01/year [1.00-1.02]), use of antimicrobials in the last 6 months (OR = 2.85[2.18-3.72]), African American (OR = 1.99 [1.66-2.37]), Asian (OR = 3.39 [2.63-4.37]), and Hispanic (OR = 2.10 [1.72-2.55]) races were independently associated with FQ-resistant rectal cultures. The overall infectious rate was 1.1% (56/5214) and the sepsis rate was 0.46% (24/5214). The infection rate in the FQ-resistant group was 3.9% (43/1107) compared to FQ-sensitive group 0.3% (13/4107), p < 0.001. CONCLUSION: In this cohort, increasing age, recent antimicrobial-use, and non-Caucasian race were independent predictors of FQ-resistance in the rectal vault. As FQ-resistance is associated with infectious complications from transrectal ultrasound-guided prostate needle biopsy, understanding risk factors may assist infection control efforts.

Should We Separate the Pulmonary Surveillance Protocol for Postsurgical T1a and T1b Renal Cell Carcinoma? A Multicenter Database Analysis.

OBJECTIVE: To investigate the incidence of pulmonary metastases (PM) and the utility of the surveillance chest radiography (CXR) in detecting PM after curative treatment to better define surveillance recommendations for T1a and T1b renal cell carcinoma. MATERIALS AND METHODS: A retrospective review of a multi-institutional database was performed to include patients with renal masses treated with partial nephrectomy or radical nephrectomy. Patients were excluded for ≥T2 disease, benign pathology, and metastases. The primary outcome was the incidence of asymptomatic pulmonary lesion concerning for PM detected by CXR within 3 years. RESULTS: Five hundred sixty-eight patients met criteria of which 384 had T1a and 184 had T1b at a mean follow-up of 45 and 43 months, respectively. Patients averaged 2.96 and 2.99 CXRs for T1a and T1b with 46.8% having surveillance beyond 3 years. Indeterminate lesions were found in 5.7% (22) of T1a and 5.4% (10) in T1b of which 0.01% (2) and 1.1% (2) were confirmed PM by chest computed tomography and biopsy. Three-year CXR surveillance period detected asymptomatic PM in zero and two patients for T1a and T1b, respectively. High risk pathological features were not present in patients with PM. There was no difference in the incidence PM for patients undergoing partial nephrectomy (3/290) or radical nephrectomy (1/278) (P = .62). CONCLUSION: Our review suggests that post-treatment pulmonary surveillance should be reserved for T1b and may not be required for T1a given the low yield and false positives of CXR leading to unnecessary radiation and potential biopsies.

Predictors of Infectious Complications after Targeted Prophylaxis for Prostate Needle Biopsy.

PURPOSE: The incidence of infectious complications after transrectal ultrasound guided prostate needle biopsy is rising. We sought to identify the incidence and predictors of infection in a large cohort of men undergoing biopsy who receive targeted prophylaxis. MATERIALS AND METHODS: We retrospectively reviewed the records of 5,214 consecutive patients who underwent transrectal ultrasound guided prostate needle biopsy from January 2013 to December 2014 at UroPartners, a large urology group comprising 28 clinics in metropolitan Chicago. At 1 microbiology laboratory all swabs were processed, the presence of fluoroquinolone resistant gram-negative rods was identified and sensitivity tests were performed. Prophylaxis for biopsy was guided by rectal swab culture. Characteristics of patients with and without infectious complications were compared using the Kruskal-Wallis and chi-square tests. Multivariable logistic regression was done to determine predictors of infectious complications. Analyses were performed with R, version 2.14.2 (https://www.r-project.org/). RESULTS: Of the 5,214 biopsies performed 56 infectious (1.1%) and 24 sepsis complications (0.46%) were found. On univariable analysis nonCaucasian race and fluoroquinolone resistant microbes were predictors of infection (p <0.05). On multivariable analysis fluoroquinolone resistant rectal vault flora (OR 9.98, 95% CI 3.79-26.3) and the number of biopsy cores taken (OR 1.28 per core, 95% CI 1.04-1.54) were independent predictors of infection. CONCLUSIONS: Despite targeted prophylaxis patients with fluoroquinolone resistant rectal vault flora have higher odds of infectious complications following transrectal ultrasound guided prostate needle biopsy. In these patients one should consider using other biopsy approaches or techniques to minimize risk.

Urology Residents' Experience and Attitude Toward Surgical Simulation: Presenting our 4-Year Experience With a Multi-institutional, Multi-modality Simulation Model.

OBJECTIVE: To evaluate the Urological resident's attitude and experience with surgical simulation in residency education using a multi-institutional, multi-modality model. MATERIALS AND METHODS: Residents from 6 area urology training programs rotated through simulation stations in 4 consecutive sessions from 2014 to 2017. Workshops included GreenLight photovaporization of the prostate, ureteroscopic stone extraction, laparoscopic peg transfer, 3-dimensional laparoscopy rope pass, transobturator sling placement, intravesical injection, high definition video system trainer, vasectomy, and Urolift. Faculty members provided teaching assistance, objective scoring, and verbal feedback. Participants completed a nonvalidated questionnaire evaluating utility of the workshop and soliciting suggestions for improvement. RESULTS: Sixty-three of 75 participants (84%) (postgraduate years 1-6) completed the exit questionnaire. Median rating of exercise usefulness on a scale of 1-10 ranged from 7.5 to 9. On a scale of 0-10, cumulative median scores of the course remained high over 4 years: time limit per station (9; interquartile range [IQR] 2), faculty instruction (9, IQR 2), ease of use (9, IQR 2), face validity (8, IQR 3), and overall course (9, IQR 2). On multivariate analysis, there was no difference in rating of domains between postgraduate years. Sixty-seven percent (42/63) believe that simulation training should be a requirement of Urology residency. Ninety-seven percent (63/65) viewed the laboratory as beneficial to their education. CONCLUSION: This workshop model is a valuable training experience for residents. Most participants believe that surgical simulation is beneficial and should be a requirement for Urology residency. High ratings of usefulness for each exercise demonstrated excellent face validity provided by the course.

En Bloc Stapling of the Renal Hilum During Laparoscopic Nephrectomy: A Double-institutional Analysis of Safety and Efficacy.

OBJECTIVE: To explore the safety and efficacy of en bloc stapling of the renal hilum (EBSH) during laparoscopic nephrectomy (LNx) in a large double-institution cohort with an extended follow-up period. METHODS: We performed a retrospective review of patients undergoing LNx with EBSH between 2008 and 2014 at 2 academic medical centers. Data analyzed included tumor size, tumor pathology, operative time, estimated blood loss, and perioperative or postoperative complications. Evaluation of arteriovenous fistula (AVF) formation was assessed by postoperative imaging studies, physical examination, or new-onset diastolic hypertension. RESULTS: A total of 428 patients (mean age: 63 years) underwent LNx, of which there were a total of 433 renal units with EBSH (226 left renal units, 207 right renal units). Mean operative time was 169 minutes (range: 51-489 minutes). Mean estimated blood loss was 155 mL (range: 5 mL-2000 mL). Mean tumor size was 5.6 cm (range: 0.9-14.5 cm). EBSH was performed on 69 patients with chronic infectious and inflammatory benign conditions. Three hundred (70%) patients received post-procedural imaging. No patients developed clinical or radiographic evidence of AVF at a mean follow-up of 51 months. CONCLUSION: EBSH during LNx is efficient, effective, and safe. This large series lends further support that EBSH during LNx may not be associated with any significant risk of AVF formation at extended follow-up. We advocate that this technique is a safe alternative to ligating the renal artery and vein during LNx.

Experience improves staging accuracy of endorectal magnetic resonance imaging in prostate cancer: what is the learning curve?

INTRODUCTION: Accurate clinical staging is critical in guiding treatment for patients with prostate adenocarcinoma. Endorectal magnetic resonance imaging (MRI) has been advocated to improve staging accuracy. In order to assess the learning curve for endorectal MRI interpretation, we compared two cohorts of patients with high-risk prostate who underwent endorectal MRI at a center with limited prior exposure to this imaging modality. MATERIALS AND METHODS: Data for all patients who received a preoperative endorectal MRI followed by radical prostatectomy were prospectively collected. MRI was performed in patients with a high level of suspicion for extracapsular disease based on biopsy Gleason score, prostate specific antigen level, and digital rectal examination or if the Memorial Sloan-Kettering nomogram predicted a greater than 30% likelihood of extracapsular disease. The MRI results of our first 40 patients (group 1) and our second 40 patients (group 2) were compared to assess for improvement. RESULTS: Between October 2003 and September 2005, 80 patients underwent an endorectal MRI followed by radical prostatectomy. Mean age and median PSA were 58.4 (range 43 - 74) and 6.4 (range 0.048 -115.0), respectively. MRI findings were compared to the pathological findings from the radical prostatectomy specimen. Sensitivity, specificity, positive predictive value, and negative predictive value for detection of extracapsular disease were 31.3% versus 64.7%, 70.8% versus 78.3%, 41.7% versus 68.8%, and 60.7% versus 75.0%, respectively in group 1 versus group 2. The accuracy of MRI for detecting extracapsular extension was 52.5% in group 1 compared to 72.5% in group 2. CONCLUSIONS: In our series, endorectal MRI initially did not accurately predict tumor stage in patients with prostatic adenocarcinoma. With further experience, the accuracy of MRI substantially improved and approached the results from centers with significant experience in the interpretation of endorectal prostate MRI.

Aortic extension for en bloc transplantation of horseshoe kidneys.

INTRODUCTION: We report a technique for extending the distal aorta to facilitate the transplantation of en bloc horseshoe kidneys. TECHNICAL CONSIDERATIONS: En bloc horseshoe kidneys can be transplanted by a technique that is analogous to the en bloc transplantation of small pediatric kidneys. However, the horseshoe kidney's isthmus prevents ascent of the kidney, and the fused lower poles stay below the level of the inferior mesenteric artery. Therefore, the distal aorta is behind the isthmus. Extending the distal aorta produces adequate vessel length to simplify en bloc transplantation of horseshoe kidneys. The extra aortic length is obtained by spatulating the distal common iliac arteries on their medial surfaces and bringing them together as a "pair of pants" for about 1.5 cm. This produces an arterial conduit that branches into the left and right common iliac arteries and then rejoins at the distal aorta. The aortic extension produces a useable vascular conduit that can be anastomosed to the recipient's external iliac artery. The distal inferior vena cava is anastomosed to the external iliac vein. We used this technique in 1 patient. The transplanted kidney made urine promptly and was providing normal function with a serum creatinine of 1.1 mg/dL. CONCLUSIONS: It is preferable to transplant some horseshoe kidneys en bloc using the distal aorta and inferior vena cava for vascular anastomoses. This technique extends the distal aorta and provides adequate vessel length to facilitate en bloc transplantation.

Treatment of upper tract urothelial carcinoma: a review of surgical and adjuvant therapy.

Upper tract urothelial carcinoma is a disease entity that has not been as extensively studied and reviewed as carcinoma of the bladder. Recent advances in technology and adjuvant therapy have changed the treatment armamentarium of oncologists and urologists. A literature review was conducted that focused on newer surgical techniques, including laparoscopy and endoscopic management of upper tract disease. Adjuvant therapy including immunotherapy, chemotherapy, and radiation is also reviewed. Nephroureterectomy with removal of a bladder cuff still remains the gold standard of treatment. However, laparoscopic nephroureterectomy is quickly becoming popular, with equivalent recurrence rates. Because of the relatively recent introduction of laparoscopy into the urologic field, long-term data with respect to recurrence rates and survival rates are not yet available. Immunotherapy has also shown promise, but with higher recurrence rates than surgery. Chemotherapy and radiation also show some improvement in recurrence rates, but there have been no randomized, prospective trials. Endoscopic management is acceptable in patients with severe medical comorbidities or solitary kidneys but requires rigorous and close follow-up. Adjuvant therapy with either chemotherapy or radiation is still debated but does offer some improvement in disease-specific survival. Randomized, prospective, placebo-controlled studies are required but are difficult to perform because of the relatively low incidence and prevalence of this disease.

Prostate specific antigen remains an independent predictor of cancer at prostate biopsy in black american men but not in white men: results from a consecutive series of 914 men.

PURPOSE: Black American men may be at increased risk for prostate cancer but differences in prebiopsy parameters between black and white men have not been fully examined. Therefore, we identified the prebiopsy parameters that may be predictive of prostate cancer in black and white men. MATERIALS AND METHODS: From January 2000 to July 2004, 914 consecutive men undergoing prostate needle biopsy were prospectively examined by a single urologist. Urinary symptoms were measured by AUASS. Prebiopsy parameters recorded were PSA, free PSA, DRE, age, race, biopsy history, prostate volume, TRUS lesion and AUASS. RESULTS: Prostate biopsy was performed in 914 men with a mean age of 63.9 years. Mean PSA in the entire cohort was 11.2 ng/ml (median 5.8). Abnormal TRUS and abnormal DRE were found in 37% and 52% of men, respectively. Mean AUASS was 9.6. The overall positive biopsy rate was 37%. In black and white men the positive biopsy rate was 44% and 34%, respectively. Analysis of AUASS indicated that 47% of patients had low symptom scores (less than 7), 39% had moderate scores (8 to 19) and 14% had severe scores (20 to 35). Multivariate analysis revealed that PSA was an independent predictor of positive biopsy in black but not in white men (p = 0.001 and 0.79, respectively). Multivariate analysis also showed that race alone was an independent predictor of positive prostate biopsy (p = 0.013). CONCLUSIONS: PSA remains an independent predictor of positive prostate biopsy on multivariate analysis. Other independent predictors are black race, age, low AUASS, prostate volume, abnormal DRE, no previous biopsy and abnormal TRUS. In the black group low AUASS, PSA, no previous biopsy and DRE were unique independent predictors, while in the white group age and abnormal TRUS were unique predictors.

Increasing the number of biopsy cores improves the concordance of biopsy Gleason score to prostatectomy Gleason score.

OBJECTIVE: To evaluate taking more biopsy cores for predicting the radical prostatectomy (RP) Gleason score compared with the biopsy Gleason score, as although random sextant biopsies are the standard for a tissue diagnosis of prostate cancer, and taking more biopsies increases the detection rate, it is uncertain whether taking more cores improves the prediction of the RP Gleason score. PATIENTS AND METHODS: We analysed retrospectively 404 patients from three centres (Seattle 162, Washington 107 and Chicago 135) who had RP for prostate cancer. Six, eight or 10 biopsies were taken based on the physician's preference and the patient's characteristics. RESULTS: Before RP, 158 (39%) patients had six, 65 (16%) had eight and 181 (45%) had 10 biopsy cores taken. The accuracy of the Gleason sum of the three groups was 65/158 (41%), 26/65 (40%) and 104/181 (57.5%), respectively (P < 0.004, 10-core vs six-core). However, when comparing the Gleason score separately (i.e. 4 + 3 is not equal to 3 + 4), the accuracy of the three groups was 48/158 (30%), 20/65 (31%), and 95/181 (52.5%), respectively (P < 0.001, 10-core vs six core). CONCLUSIONS: Taking more biopsy cores improves the accuracy of the biopsy Gleason score in predicting the final Gleason score at RP; the predictive accuracy of the final Gleason score may be increased from 41% to 58% by increasing the number of biopsies from six to 10.

Absence of lower urinary tract symptoms is an independent predictor for cancer at prostate biopsy, but prostate-specific antigen is not: results from a prospective series of 569 patients.

PURPOSE: Prostate needle biopsy (PNB) is the definitive method for the diagnosis of prostate cancer. Our objective was to evaluate prebiopsy parameters, including lower urinary tract symptoms, that may be predictive of positive biopsy. PATIENTS AND METHODS: We performed a prospective review of 569 consecutive men who underwent transrectal ultrasound (TRUS)-guided PNB. The prebiopsy variables recorded included age, prostate-specific antigen (PSA) levels, prostate volume (PV), percent free PSA levels, suspicious digital rectal examination (DRE) findings, TRUS-detected lesions, race, and American Urologic Association Symptom Score (AUASS). RESULTS: Low AUASS, PV, patient age, and abnormal TRUS findings were independent predictors of positive PNB results (P < 0.05). In patients with PSA levels between 4 and 10 ng/mL, the positive predictive value of a low AUASS (< 8) in predicting a positive PNB result is 68.7%. When race was considered (black vs. white), univariate analysis (UVA) indicated that race was a significant predictor (P = 0.034) of positive PNB. A subgroup analysis was performed for black men undergoing PNB (n = 256). Multivariate analysis (MVA) indicates that abnormal TRUS findings; low AUASS, PV, and PSA levels; and absence of prior biopsy are all independent predictors of PNB in the black patient group. A final subgroup analysis (UVA and MVA) was performed for white men (n = 310). Only patient age and PV demonstrated significance as independent predictors of PNBs in this group. CONCLUSION: This prospective analysis of 569 men demonstrates that traditional indicators for PNB (abnormal DRE findings and PSA levels) are not significant predictors of prostate cancer. Independent predictors for prostate included age, low AUASS, low PV, and abnormal TRUS findings. A low AUASS (indicative of the absence of benign disease) is an important predictor of prostate cancer.

Is routine postoperative chest radiography needed after open nephrectomy?

OBJECTIVES: To assess whether routine postoperative chest radiography (CXR) is required after open nephrectomy for the detection and possible management of a pneumothorax. It has become the standard of care by many urologists to obtain routine postoperative CXRs after open nephrectomy to assess for the presence of a pneumothorax. However, at our institution, very few patients have developed a pneumothorax postoperatively, and, furthermore, the CXR findings almost never affected the clinical management. METHODS: Retrospective data were collected on the last 150 open nephrectomies performed by two urologists at our institution. All laparoscopic nephrectomies and thoracoabdominal nephrectomies were excluded from analysis. RESULTS: A total of 150 patients underwent open nephrectomy between 1998 and 2003. The procedure was performed with an anterior subcostal, 11th rib, 12th rib, midline, and 10th rib incision in 60 (40%), 51 (34%), 18 (12%), 20 (13.3%), and 1 (0.67%) patient, respectively. Of the 150 patients, 92 (61.3%) underwent postoperative CXR and 58 (38.7%) did not. Of the 150 patients, 92 of whom had undergone postoperative CXR, 4 (2.7%) had a postoperative pneumothorax. One of these patients (0.67%) received a chest tube. Of the 4 patients with a pneumothorax, 3 had had a recognized pleural tear that was repaired at nephrectomy and the fourth had had an unrecognized pleural injury. CONCLUSIONS: Routine postoperative CXRs are not needed after open nephrectomy. Obtaining a selective CXR when a recognized intraoperative pleural tear has occurred, a central line is placed, the physical examination reveals an abnormality (ie, decreased breath sounds), or the patient experiences respiratory difficulties in the postoperative period is safe, cost-effective, and decreases the radiation exposure to patients.

Schwannoma of a seminal vesicle.

We present the first reported case of a schwannoma of the seminal vesicle that occurred in a 48-year-old man who presented with right lower quadrant abdominal pain. Computed tomography scan and magnetic resonance imaging revealed a mass in the patient's right seminal vesicle. The patient was also found to have a rising prostate-specific antigen level and underwent a transrectal ultrasound-guided biopsy of the prostate and seminal vesicles, which revealed prostate cancer and schwannoma of the seminal vesicle, respectively. Radical prostatectomy with en bloc removal of the seminal vesicle mass was performed and the patient has been free of disease 24 months postoperatively.