Assessment of energy density usage during 180W lithium triborate laser photoselective vaporization of the prostate for benign prostatic hyperplasia. Is there an optimum amount of kilo-Joules per gram of prostate?

OBJECTIVES: To assess the effect of energy density (kJ/mL) applied on adenoma during photoselective vaporization of the prostate (PVP) treatment for benign prostate hyperplasia (BPH) on functional outcomes, prostate-specific antigen (PSA) reduction and complications. PATIENTS AND METHODS: After exclusions, a total of 440 patients who underwent GreenLight (tm) laser XPS-180W lithium triborate PVP for the treatment of BPH were retrospectively reviewed. Data were collected from seven different international centres (Canada, USA, UK and France). Patients were stratified into four energy density groups (kJ/mL) according to intra-operative energy delivered and prostate volume as determined by preoperative transrectal ultrasonography (TRUS): group 1: <3 kJ/mL; group 2: 3-5 kJ/mL; group 3: 5-7 kJ/mL; and group 4: ≥7 kJ/mL. Energy density groups were chosen arbitrarily. PSA reduction and functional outcomes (International Prostate Symptom Score, quality of life, post-void residual urine volume, maximum urinary flow rate) were compared at 6, 12 and 24 months. Peri-operative complications and retreatment rates were also compared among the groups. RESULTS: The PSA reduction rates at 24 months after the procedure were 51, 61, 79 and 83% for the energy density groups <3, 3-5, 5-7 and ≥7 kJ/mL, respectively (P ≤ 0.01). This held true after accounting for baseline confounders. Energy density was not associated with higher complication rates, including haematuria, stricture formation, incontinence, refractory urinary retention, urinary tract infection and conversion to transurethral resection of the prostate. Functional outcomes at 2 years of follow-up were equivalent among the groups (P > 0.05 for all) and similar retreatment rates were observed (P = 0.36). CONCLUSION: Higher energy usage per cc of prostate was associated with a more significant reduction in PSA level (>50%) at 6, 12 and 24 months, suggesting increased vaporization of adenoma tissue; however, this did not translate into differences in functional outcomes at 2-year follow-up.

Erectile function recovery after robotic-assisted radical prostatectomy (RARP): long term exhaustive analysis across all preoperative potency categories.

INTRODUCTION: To evaluate erectile function recovery following robotic-assisted radical prostatectomy (RARP) according to preoperative sexual health inventory for men (SHIM) score stratification. MATERIALS AND METHODS: We prospectively collected data on 250 consecutive patients who underwent RARP by a single surgeon between October 2006 and October 2012. Thirty-six patients were excluded because of lack of preoperative SHIM score. All patients had a minimum follow up of 2 years. Patients were divided into four groups according to their preoperative SHIM score: group 1 with normal potency (SHIM 22-25), group 2 with mild ED (SHIM 17-21), group 3 with mild-moderate ED (SHIM 12-16) and group 4 with moderate-severe ED (SHIM 1-11). Patients were followed at 3, 6, 9, 12, 18, 24 months intervals and twice yearly thereafter. SHIM questionnaire and erection hardness scale (EHS) score were collected at each visit. Potency was defined as successful penetration during intercourse (EHS score 3-4) with or without phosphodiesterase type 5-inhibitor (PDE5-I). RESULTS: After exclusion, 214 patients were evaluated. The number of patients in group 1, 2, 3 and 4 were 95, 59, 26 and 34, respectively. At 3, 6, 9, 12, 18, 24 months, SHIM scores and potency rates were statistically different between groups 1 versus 2 versus 3 versus 4 (p < 0.01, at each time point). Patients in each group 1, 2 and 3 showed a statistically significant improvement in potency rates and SHIM scores at consecutive follow up visits up to 24 months (p < 0.01, for each potency group). Potency rates at 24 months for groups 1 to 4 were 83.3%, 54.5%, 50.0%, and 20.7%, respectively (p < 0.001). CONCLUSION: For proper patient counseling and better prediction of erectile function recovery after RARP, it is important to stratify patients according to preoperative SHIM scores. Setting realistic expectations may increase patient satisfaction.

Saudi Urological Association consensus guidelines on the use of robotic surgery in urology.

Over the past three decades, minimally invasive robotic technology has evolved substantially in urological practice, replacing many open procedures and becoming part of routine clinical practice. The Health Sector Transformation Program for the Kingdom's Vision 2030 aims to restructure the health sector and optimize its status and prospects as an effective and integrated ecosystem centered on the patient's health. Therefore, this consensus seeks to endorse the clinical practice guidelines for robotic surgery (RS) in the KSA, highlighting its effectiveness, safety, and favorable outcomes compared to open and laparoscopic surgeries in certain procedures when used by trained surgeons in well-structured RS programs.

Robotic-assisted excision of a juxta renal retroperitoneal schwannoma.

Retroperitoneal schwannoma is a rare benign tumor of the peripheral nerve Schwann sheath. We, herein, report the case of a 74-year-old woman who presented with vague abdominal pain. Computed tomography imaging revealed a retroperitoneal mass that is medial to the right kidney. The patient underwent robotic excision of the tumor with the pathology revealing schwannoma. We report this case due to the scarcity of this disease entity, especially at this location and to emphasize the indication and value of robotic technology in different pathological processes retroperitoneally.

Long-term urinary functional outcome of vesicourethral anastomosis with bidirectional poliglecaprone (Monocryl®) vs. barbed polyglyconate suture (V-LocTM 180) in robot-assisted radical prostatectomy.

INTRODUCTION: We aimed to evaluate urinary continence recovery following robot-assisted radical prostatectomy (RARP) using monofilament poliglecaprone (Monocryl®) suture vs. barbed suture (V-LocTM 180) during vesicourethral anastomosis (VUA). METHODS: In this prospective, observational cohort, data were collected on 322 consecutive patients. All patients underwent continuous, bidirectional, single-layer running anastomosis with either 3.0 monofilament suture (n=141) or 3.0 barbed suture (n=181). The primary outcome was continence recovery defined as time to 0 pad at one, three, six, 12, and 24 months following surgery. RESULTS: Continence rates were significantly better with monofilament VUA at all followup time points up to one year. Median time to continence was one month vs. five months in the monofilament group vs. barbed group, respectively (p<0.001). Continence rates in monofilament suture vs. barbed group at one, three, six, 12, and 24 months were 56% vs. 26% (p<0.001), 73% vs. 36.4% (p<0.001), 84.4% vs. 60.2% (p<0.001), 90.8% vs. 71.9% (p<0.001), and 93.5% vs.87.1% (p=0.1), respectively. Anastomosis time was shorter in the barbed group, with a median of 23 vs. 30 minutes (p<0.001). Patients anastomosed with Monocryl suture had smaller prostate weight (median 42.5 g vs. 50 g; p<0.001) and harbored less advanced disease (T2a-c 76.6 vs. 74%; p=0.01) relative to patients treated with V-Loc 180 suture. However, in a multivariate Cox logistic regression analyses, independent predictors of continence recovery were suture type (hazard ratio [HR] 53; 95% confidence interval [CI] 0.41-0.68; p=0.02] and prostate size (HR 0.99; 95% CI 0.98-0.99; p<0.001). CONCLUSIONS: Barbed VUA contributed to delayed continence recovery compared to monofilament poliglecaprone suture during the first year post-RARP. However, no statistically significant difference was recorded at two years post-RARP. These results warrant special attention, especially with the widespread use of barbed suture in recent years.

Perioperative predictors for post-prostatectomy urinary incontinence in prostate cancer patients following robotic-assisted radical prostatectomy: Long-term results of a Canadian prospective cohort.

INTRODUCTION: We aimed to report the impact of perioperative factors that have not been well-studied on continence recovery following robotic-assisted radical prostatectomy (RARP). METHODS: We analyzed data of 322 men with localized prostate cancer who underwent RARP between October 2006 and May 2015 in a single Canadian centre. All patients were assessed at one, three, six, 12, and 24 months after surgery. We evaluated risk factors for post-prostatectomy urinary incontinence from a prospectively collected database in multivariate Cox regression analysis. The primary endpoint was continence, defined as 0 pad usage per day. RESULTS: 0-pad continence rates were 126/322 (39%), 187/321 (58%), 222/312 (71%), 238/294 (80%), and 233/257 (91%) at one, three, six, 12, and 24 months, respectively. Bladder neck preservation (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.5-0.99; p=0.04), and prostate size (HR 0.99; 95% CI 0.98-0.99; p=0.02) were independent predictors of continence recovery after RARP. Smoking at time of surgery predicted delayed continence recovery on multivariate analysis (HR 1.42; 95% CI 1.01-1.99; p=0.04). Neurovascular bundles preservation was associated with continence recovery after 24 months. No statistically significant correlation was found with other variables, such as age, body mass index, Charlson comorbidity index, preoperative oncological baseline parameters, presence of median lobe, or thermal energy use. CONCLUSIONS: Our results confirmed known predictors of postprostatectomy incontinence (PPI), namely bladder neck resection and large prostate volume. Noteworthy, cigarette smoking at the time of RARP was found to be a possible independent risk factor for PPI. This study is hypothesis-generating.

Evaluation of Surgical Outcomes with Photoselective GreenLight XPS Laser Vaporization of the Prostate in High Medical Risk Men with Benign Prostatic Enlargement: A Multicenter Study.

OBJECTIVE: To evaluate the safety and short-term outcomes of photoselective vaporization of the prostate (PVP) using GreenLight XPS™ in treatment of high medical risk (HMR) men. METHODS: A multicenter retrospective analysis of 941 men who underwent PVP between August 2010 and August 2014 was performed. Patients were considered HMR if they had an American Society of Anesthesiologists physical status score ≥3. Postoperative adverse events, unexpected postoperative medical provider visits after intervention, and functional urinary outcomes were examined. RESULTS: HMR men (n = 273) were older (mean age 72.3 ± 8.1 years vs 67.1 ± 9 years, p ≤ 0.01), had larger prostate volumes (82.8 ± 48.2 g vs 73.7 ± 49.4 g, p < 0.01), and were more likely to be on anticoagulant and antiplatelet medications (all p ≤ 0.01). Moreover, overall operative time (65 ± 35.1 minutes vs 53.9 ± 24.9 minutes), energy delivered (313.4 ± 207 kJ vs 258 ± 164 kJ), and energy density used (4.2 ± 3.8 kJ/g vs 3.8 ± 3 kJ/g) were greater in the HMR group (all p ≤ 0.05). Although HMR men were more often treated in a hospital setting (p ≤ 0.01), there were no differences in intraoperative adverse events. At 6 months, both groups had notable improvements from baseline for International Prostate Symptom Score, quality of life due to urinary symptoms, maximum urinary flow rate, postvoid residual urine volume, and prostate-specific antigen. Regarding safety, the two groups had comparable 90-day Clavien-Dindo complication rates, numbers of urgent care visits, and numbers of outpatient consultations. HMR men, however, had more hospital readmissions within 90 days postsurgery (3.7% vs 1.3%; p = 0.04). CONCLUSIONS: Despite older age, greater comorbidity, and significant use of anticoagulants, HMR men who undergo photoselective vaporization benefit from symptom improvement and show no clinical difference in adverse event profiles. GreenLight-XPS produces similar short-term outcomes in patients with significant comorbidities when compared with healthy patients.

Error reporting from the da Vinci surgical system in robotic surgery: A Canadian multispecialty experience at a single academic centre.

INTRODUCTION: The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. METHODS: A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. RESULTS: Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. CONCLUSIONS: Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.

Safety, Perioperative, and Early Functional Outcomes of Vapor Incision Technique Using the GreenLight XPS 180 W System: Direct Comparison with Photoselective Vaporization of the Prostate.

OBJECTIVES: To compare perioperative parameters, safety, and short-term functional outcomes between GreenLight 180 W-XPS photoselective vaporization of the prostate (PVP) and vapor incision technique (VIT). MATERIALS AND METHODS: A total of 956 men were treated at five high-volume centers in Canada and the United States between 2000 and 2014 for benign prostatic hyperplasia. Perioperative parameters, complications, and early functional outcomes were retrospectively compared. One-to-one propensity score matching was performed to adjust for baseline differences between treatment groups. Subgroup stratified comparative analysis was performed according to preoperative prostate volume 80 cc or less vs greater than 80 cc on transrectal ultrasound (259 and 185 patients, respectively). RESULTS: VIT allowed greater energy delivery and energy density, but operative time and laser time were longer with greater use of MoXy fibers when compared with PVP (all p < 0.05). Improvements in outcomes at 6 months, including International Prostate Symptom Score, quality of life score, and uroflowmetry parameters, were significantly greater after VIT when compared with baseline. VIT was associated with significantly greater 6-month prostate-specific antigen (PSA) reduction (63% vs 50%, p = 0.01). No differences in intraoperative complications were observed between treatment groups. CONCLUSION: VIT is safe and efficacious, providing greater improvements in functional outcomes and PSA reduction at 6 months in comparison with PVP. These results reflect the larger amount of adenoma removed. Yet, it is associated with longer operative time and greater use of MoXy fibers. Long-term follow-up is needed to accurately assess functional outcomes and retreatment rates.

Feasibility of planned mini-laparotomy and adhesiolysis at the time of robotic-assisted radical prostatectomy in patients with prior major abdominal surgery.

INTRODUCTION: Our aim was to report our experience on the feasibility of completing radical prostatectomy robotically after planned open adhesiolysis for prior major abdominal surgery with previous midline laparotomy scar. METHODS: We searched our prospectively collected database of robotic assisted-radical prostatectomy (RARP) performed between October 2006 and October 2012 by a single fellowship-trained surgeon to identify all patients who underwent planned initial mini-laparotomy for release of abdominal adhesions at time of RARP. Among 250 RARP patients, five patients fulfilled these criteria. RESULTS: All patients had prostatectomy completed robotically. The mean values of patients' demographics were as follows: Age 61.8 years (range 54-69), body mass index 30.7 (range 24.3-45.3), and prostate volume 41.5 ml (range 30.8-54). Mean operative time was 245 min (range 190-280) and estimated blood loss 410 ml (range 300-650). Median hospital stay was one day (range 1-7). Postoperatively, there was one prolonged ileus, which resolved spontaneously, and one myocardial infarction. CONCLUSIONS: Robotic completion of radical prostatectomy after open adhesiolysis is feasible. This approach maintains most minimally invasive advantages of RARP, despite a slightly longer hospital stay. In the best interest of patients, robotic surgeons are encouraged to finish the case robotically rather than attempting an open approach.

CAPRA-S predicts outcome for adjuvant and salvage external beam radiotherapy after radical prostatectomy.

INTRODUCTION: We aimed to evaluate the predictive value of the Cancer of the Prostate Risk Assessment Postsurgical Score (CAPRA-S) for patients treated with radical prostatectomy followed by subsequent external beam radiotherapy (EBRT). METHODS: A total of 373 patients treated with EBRT between January 2000 and June 2015 were identified in the institutional database. Followup and complete CAPRA-S score were available for 334 (89.5%) patients. CAPRA-S scores were sorted into previously defined categories of low- (score 0-2), intermediate- (3-5), and high-risk (6-12). Time to biochemical recurrence (BCR) was defined as prostate-specific antigen (PSA) >0.20 ng/mL after EBRT. Survival analyses were performed using the Kaplan-Meier method and comparisons were made using the log-rank test. RESULTS: Overall median time from surgery to EBRT was 18 months (interquartile range [IQR] 8-36) and median followup since EBRT was 48 months (IQR 28-78). CAPRA-S predicted time to BCR (<0.001), time to palliative androgen-deprivation therapy (ADT) (p=0.017), and a trend for significantly predicting overall survival (OS, p=0.058). On multivariate analysis, the CAPRA-S was predictive of time to BCR only (low-risk vs. intermediate-risk; hazard ratio [HR] 0.14, 95% confidence interval [CI] 0.043-0.48, p=0.001). The last PSA measurement before EBRT as a continuous and grouped variable proved highly significant in predicting all outcomes tested, including OS (p≤0.002). CONCLUSIONS: CAPRA-S predicts time to BCR and freedom from palliative ADT, and is borderline significant for OS. Together with the PSA before EBRT, CAPRA-S is a useful, predictive tool. The main limitation of this study is its retrospective design.

Radiation therapy after radical prostatectomy: A single-centre radiation oncology experience in trends of referral and treatment practices.

INTRODUCTION: Our objective was to assess whether referral and treatment practices have changed since publication of the Southwest Oncology Group (SWOG) 8794 Trial in 2009, the first randomized study to demonstrate an overall survival advantage of adjuvant radiation therapy (RT) after radical prostatectomy (RP). METHODS: We retrospectively reviewed all medical charts of men who received RT at our institution between 2004 and 2014 following RP. All RT was conducted by a single radiation oncologist (DT). We divided the cohort into 2 groups according to first referral date before or after the SWOG 8794 trial publication (i.e., before 2010 and after 2010). RESULTS: Medical charts were available for 161/165 patients (97.6%). RP was performed at the same institution in 58% of cases. The median time between surgery and first referral for RT decreased significantly from 672 days (interquartile range [IQR] 295-1449) before 2010 to 300 days (IQR 225-1023) after 2010 (p = 0.04). This trend was associated with lower median prostate-specific antigen (PSA) at RT referral (0.26 µg/L [IQR 0.17-0.48] vs. 0.46 µg/L [IQR 0.25-0.90], respectively; p = 0.001). Androgen-deprivation therapy with RT nearly tripled over time from 13% before 2010 to 37% after 2010 (p = 0.003). Throughout the study period, the time interval between surgery and RT initiation was positively correlated with pT-stage (p = 0.001), Gleason score (p = 0.005) and PSA doubling time (p < 0.001). CONCLUSIONS: At our tertiary-referral academic institution, post-RP patients are notably referred earlier for RT and at lower PSA values compared to men treated prior to 2010. Further study is necessary to evaluate this impact on biochemical recurrence-free survival.

Uroflow Stop Test and Potency Recovery: A Surrogate for Pelvic Floor Integrity Post Robotic-Assisted Radical Prostatectomy?

OBJECTIVE: To study the relation between uroflow Stop Test and early recovery of potency following robot-assisted radical prostatectomy (RARP). We recently showed that the ability to completely stop urine flow during voiding, measured objectively by uroflowmetry at the time of catheter removal (uroflow Stop Test) can predict early urinary continence recovery following RARP. MATERIALS AND METHODS: In this prospective observational cohort, data were collected on 108 patients operated by a single surgeon (AEH). Eighty patients had a positive uroflow Stop Test (group one) and 28 had a negative Stop Test (group two). Patients were followed for a minimum of 2 years. Covariates included age, body mass index, international prostate symptom score and sexual health inventory for men scores, prostate-specific antigen, tumor stage, prostate volume, nerve sparing status, and estimated blood loss. RESULTS: Preoperative characteristics were comparable between both groups except nerve sparing and prostate-specific antigen which were statistically higher in group one (P <.05). Early 3- and 6-months recovery of erectile function was significantly higher in group one. Potency rates in group one and two at 1, 3, 6, 9, 12, 18, and 24 months were 25% vs 14.3% (P = .241), 54.5% vs 18.5% (P = .001), 55.4% vs 18.5% (P = .001), 56.4% vs 36% (P = .084), 66.6% vs 50% (P = .141), 65.5% vs 56% (P = .404) and 73.2% vs 57.7% (P = .160) respectively. Uroflow Stop Test was independent predictor of early potency recovery on multivariate regression analysis at 6 months [odds ratio 6.042 (confidence interval 95% 1.496-24.413) P = .012]. CONCLUSION: Uroflow Stop Test is simple and can help predict early potency recovery following RARP.

Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon's experience.

INTRODUCTION: We evaluated the average time required to complete individual steps of robotic-assisted radical prostatectomy (RARP) by an expert RARP surgeon. The intent is to help establish a time-based benchmark to aim for during apprenticeship. In addition, we aimed to evaluate preoperative patient factors, which could prolong the operative time of these individual steps. METHODS: We retrospectively identified 247 patients who underwent RARP, performed by an experienced robotic surgeon at our institution. Baseline patient characteristics and the duration of each step were recorded. Multivariate analysis was performed to predict factors of prolonged individual steps. RESULTS: In multivariable analysis, obesity was a significant predictor of prolonged operative time of: docking (odds ratio [OR] 1.96), urethral division (OR 3.13), and vesico-urethral anastomosis (VUA) (OR 2.63). Prostate volume was also a significant predictor of longer operative time in dorsal vein complex ligation (OR 1.02), bladder neck division (OR 1.03), pedicle control (OR 1.04), urethral division (OR 1.02), and VUA (OR 1.03). A prolonged bladder neck division was predicted by the presence of a median lobe (OR 5.03). Only obesity (OR 2.56) and prostate volume (OR 1.04) were predictors of a longer overall operative time. CONCLUSIONS: Obesity and prostate volume are powerful predictors of longer overall operative time. Furthermore, both can predict prolonged time of several individual RARP steps. The presence of a median lobe is a strong predictor of a longer bladder neck division. These factors should be taken into consideration during RARP training.

Prevalence and risk factors of contralateral extraprostatic extension in men undergoing radical prostatectomy for unilateral disease at biopsy: A global multi-institutional experience.

INTRODUCTION: We assessed the incidence of contralateral prostate cancer (cPCa), contralateral EPE (cEPE) and contralateral positive surgical margins (cPSM) in patients diagnosed preoperatively with unilateral prostate cancer and evaluated risk factors predictive of contralateral disease extension. METHODS: The occurrence of cPCa, cEPE and cPSM and the side-specific nerve-sparing technique performed were collected postoperatively from 327 men diagnosed with unilateral prostate cancer at biopsy. Parameters, such as the localization, proportion, and percentage of cancer in positive cores, were prospectively collected. RESULTS: Overall, 50.5% of patients had bilateral disease, and were at higher risk when associated with a positive biopsy core at the apex (p = 0.016). The overall incidence of ipsilateral EPE and cEPE were 21.4% and 3.4%, respectively (p < 0.001). Compared to cPCa, ipsilateral disease was at an almost 4-fold higher risk of extending out of the prostate (p < 0.001). None of the criteria tested were identified as useful predictors for cEPE. The low incidence of cEPE in our cohort could limit our ability to detect significance. The overall incidence of ipsilateral PSM and cPSM were 15.3% and 5.8%, respectively (p < 0.001). More aggressive nerve-sparing was not associated with a higher incidence of PSM. Prostate sides selected for more aggressive nerve-sparing were associated with younger patients (p < 0.001), a smaller prostate (p = 0.006), and a lower percentage of cancer in biopsy material (p = 0.008). CONCLUSION: Although the risk of cPCa is high in patients diagnosed with unilateral prostate cancer at biopsy, the risk of cEPE and cPSM is low, yet not insignificant. Contralateral aggressive nerve-sparing should be used with caution and should not compromise oncological outcome.