Bilateral Peritoneal Flaps Reduce Incidence and Complications of Lymphoceles after Robotic Radical Prostatectomy with Pelvic Lymph Node Dissection-Results of the Prospective Randomized Multicenter Trial ProLy.

PURPOSE: The purpose of this study was to investigate the effect of a surgically constructed bilateral peritoneal flap (PIF) as an adjunct to robot-assisted radical prostatectomy (RARP) and pelvic lymph node dissection (PLND) on the incidence of lymphoceles. MATERIALS AND METHODS: A total of 530 men with localized prostate cancer underwent a RARP with bilateral extended standardized PLND in a prospective randomized controlled trial. In group A, a PIF was created by suturing the margins of the bladder peritoneum to the ipsilateral endopelvic fascia at 2 points on each side. In group B, no PIF was created. The patients were followed 30 and 90 days after the surgery to assess the incidence, extent and treatment of lymphoceles. RESULTS: Lymphoceles occurred in 22% of group A patients and 33% of group B patients (p=0.008). Symptomatic lymphoceles were observed in 3.3% of group A patients and 8.1% of group B patients (p=0.027). Lymphoceles requiring intervention occurred significantly less frequently in group A patients (1.3%) than in group B patients (6.8%, p=0.002). The median lymphocele size was 4.3 cm in group A and 5.0 cm in group B (p=0.055). No statistically significant differences were observed in minor or major complications unrelated to lymphocele, blood loss, or surgical time between groups A and B. CONCLUSIONS: Bilateral PIFs in conjunction with RARP and PLND significantly reduce the total incidence of lymphoceles, the frequency of symptomatic lymphoceles and the rate of associated secondary interventions.

Are there limits of robotic partial nephrectomy? TRIFECTA outcomes of open and robotic partial nephrectomy for completely endophytic renal tumors.

BACKGROUND: To compare the outcomes of robot-assisted (RAPN) and open partial nephrectomy (OPN) for completely endophytic renal tumors. METHODS: Consecutive patients undergoing OPN or RAPN for entirely endophytic tumors in four high-volume centers between 2008 and 2016 were identified. Endophytic masses were identified based on sectional imaging. Patient characteristics and surgical outcome were compared using Mann-Whitney-U-test and chi-squared-tests. Uni- and multivariate analyses were performed to identify predictors of TRIFECTA achievement and excisional volume loss. RESULTS: Out of 1128 patients, 10.9% (64) of RAPN and 13.9% (76) of OPN underwent surgery for entirely endophytic tumors. Operative time was longer for RAPN (169 vs 140 min, P = 0.03) while ischemia time was shorter (13 vs 18 min, P = 0.001). Complication rates were comparable (21% OPN vs 22% RAPN, P = 0.91) and TRIFECTA achievement was not different between the groups (68% OPN vs 75% RAPN, P = 0.39). In multivariate analyses type of surgery was not associated with TRIFECTA achievement or excisional volume loss. Here, only tumor complexity (OR 0.48, P = 0.001) and size (OR 1.01, P = 0.002) were independent predictors. CONCLUSION: For entirely endophytic tumors, both RAPN and OPN offer good TRIFECTA achievement. This encourages the use of NSS even for these highly complex tumors using the surgeon's preferred approach.

Outcome of Robotic Radical Prostatectomy in Men Over 74.

INTRODUCTION: We set out to evaluate outcomes in patients over 74 after robotic radical prostatectomy. MATERIALS AND METHODS: Six hundred forty-seven patients over 74 (≥75) were analyzed for preoperative factors (body mass index [BMI], American Society of Anestesiologists classification [ASA], prostate-specific antigen [PSA], International prostate symptome score [IPSS], International index of erectile function [IIEF]), operative and perioperative characteristics (technique, erythrocyte conc., complications), and histopathological results. After 12 months, following items were assessed: PSA, frequency of urine loss, number of pads used (including safety), incontinence at night, and potency as quantified by IIEF-5. RESULTS: Mean age in the group <75 was 64.8 years (range 46-74 years) and in the group ≥75 76.9 years (75-88). No statistically significant differences could be detected in terms of BMI, ASA score, or preoperative PSA, respectively. IPSS and IIEF were significantly worse in the group ≥75. Major complications (>Clavien-Dindo III) were found in 1.6% vs. 1.3% (≥75) of cases. Minor complications were encountered in 22.8% vs. 26.3% (≥75). There was a remarkably high percentage of locally advanced disease (73.3% vs. 71.0%) in both groups. Patients ≥75 showed a tendency toward more aggressive cancer and more frequent nodal involvement; we found a higher percentage of R1-resections (19.5% vs. 30.4%, p < 0.05) and PSA relapse after 1 year (12.3% vs. 22.8%, p < 0.05). Twelve months pad-free continence rate (69.9% vs. 63.2%) showed no statistically significant difference between both groups as did the preservation rate of erectile function. CONCLUSION: We could show that robotic prostatectomy can be carried out safely with good functional and histopathological results in patients ≥75. It is therefore questionable if elderly patients can be precluded from curative radical treatment solely because of their age.

Minimally Invasive Repair of a Prostatorectal Fistula with an Over-the-Scope Rectal Clip.

Background: Fistulae between the prostatic urethra and the rectum are rare. They may result from prostatic or rectal surgery. Predisposing factors are previous radiation or immunosuppression. The repair of such fistulae usually involves major surgery. Recently, clips that can be deployed over an endoscope have been developed to close gastrointestinal fistulae or access points for natural orifice surgery. We report the first case of effective treatment of a prostatorectal fistula with a rectal "over-the-scope" clip. Case Presentation: A 64-year-old man under chronic immunosuppression presented with an iatrogenic fistula between the prostatic urethra and the rectum after transurethral resection of the prostate. A transverse colostomy was placed but the fistula failed to heal conservatively. The fistula was effectively closed with an endorectal clip. Six weeks after the procedure, spontaneous micturition was started. Two weeks further, the colostomy was reversed. At 32 months of follow-up, the remains closed, micturition is unimpaired. Conclusion: In select cases of prostatorectal fistula, an endorectal clip may be effectively used for closure.