Early surgical outcomes and oncological results of robot-assisted partial nephrectomy: a multicentre study.

OBJECTIVE: To describe a multicentre experience of robot-assisted partial nephrectomy (RAPN) in northern England, with focus on early surgical outcomes and oncological results. PATIENTS AND METHODS: All consecutive patients undergoing RAPN at four tertiary referral centres in northern England in the period 2012-2015 were included for analysis. RAPN was performed via a transperitoneal approach using a standardized technique. Prospective data collection was performed to capture preoperative characteristics (including R.E.N.A.L. nephrometry score), and peri-operative and postoperative data, including renal function. Correlations between warm ischaemia time (WIT), positive surgical margin (PSM) rate, complication rates, R.E.N.A.L. nephrometry scores and learning curve were assessed using univariate and multivariate analyses. RESULTS: A total of 250 patients (mean age 58.1 ± 13 years, mean ± sd body mass index 27.3 ± 7 kg/m2 ) were included, with a median (range) follow-up of 12 (3-36) months. The mean ± sd tumour size was 30.6 ± 10 mm, mean R.E.N.A.L. nephrometry score was 6.1 ± 2 and 55% of tumours were left-sided. Mean ± sd operating console time was 141 ± 38 min, WIT 16.7 ± 8 min and estimated blood loss 205 ± 145 mL. There were five conversions (2%) to open/radical nephrectomy. The overall complication rate was 16.4% (Clavien I, 1.6%; Clavien II, 8.8%; Clavien III, 6%; Clavien IV/V; 0%). Pathologically, 82.4% of tumours were malignant and the overall PSM rate was 7.3%. The mean ± sd preoperative and immediate postoperative estimated glomerular filtration rates were 92.8 ± 27 and 80.8 ± 27 mL/min/1.73 m2 , respectively (P = 0.001). In all, 66% of patients remained in the same chronic kidney disease category postoperatively, and none of the patients required dialysis during the study period. 'Trifecta' (defined as WIT < 25 min, negative surgical margin status and no peri-operative complications) was achieved in 68.4% of patients overall, but improved with surgeon experience. PSM status and long WIT were significantly associated with early learning curve. CONCLUSION: This is the largest multicentre RAPN study in the UK. Initial results show that RAPN is safe and can be performed with minimal morbidity. Early oncological outcomes and renal function preservation data are encouraging.

Corrigendum to "RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned" [Eur. Urol. Open Sci. 54 (2023) 33-42].

[This corrects the article DOI: 10.1016/j.euros.2023.05.007.].

Definition of a Structured Training Curriculum for Robot-assisted Radical Cystectomy with Intracorporeal Ileal Conduit in Male Patients: A Delphi Consensus Study Led by the ERUS Educational Board.

Robot-assisted radical cystectomy (RARC) continues to expand, and several surgeons start training for this complex procedure. This calls for the development of a structured training program, with the aim to improve patient safety during RARC learning curve. A modified Delphi consensus process was started to develop the curriculum structure. An online survey based on the available evidence was delivered to a panel of 28 experts in the field of RARC, selected according to surgical and research experience, and expertise in running training courses. Consensus was defined as ≥80% agreement between the responders. Overall, 96.4% experts completed the survey. The structure of the RARC curriculum was defined as follows: (1) theoretical training; (2) preclinical simulation-based training: 5-d simulation-based activity, using models with increasing complexity (ie, virtual reality, and dry- and wet-laboratory exercises), and nontechnical skills training session; (3) clinical training: modular console activity of at least 6 mo at the host center (a RARC case was divided into 11 steps and steps of similar complexity were grouped into five modules); and (4) final evaluation: blind review of a video-recorded RARC case. This structured training pathway will guide a starting surgeon from the first steps of RARC toward independent completion of a full procedure. Clinical implementation is urgently needed. PATIENT SUMMARY: Robot-assisted radical cystectomy (RARC) is a complex procedure. The first structured training program for RARC was developed with the goal of aiding surgeons to overcome the learning curve of this procedure, improving patients' safety at the same time.

Cadaveric analysis of periprostatic nerve distribution: an anatomical basis for high anterior release during radical prostatectomy?

PURPOSE: An accurate, complete understanding of the prostate neuroanatomy is required to optimize nerve sparing techniques during radical prostatectomy. However, the precise topography and function of the periprostatic nerves remain contentious and there is uncertainty about which nerve sparing technique is most optimal. We accurately quantified the distribution, precise localization and cross-sectional area of periprostatic neural tissue using cadaveric specimens. MATERIALS AND METHODS: We analyzed 13 cadaveric hemipelves using hematoxylin and eosin stained sections from the base, mid zone and apex of each prostate. Each section was digitized and divided into 6 sectors numbered clockwise. Analysis was performed using National Institutes of Health ImageJ software to calculate the total periprostatic neural cross-sectional area per sector. RESULTS: Calculating the total neural cross-sectional area highlighted a decrease from prostate base to mid zone to apex of 24.7, 19.7 and 13.7 mm(2), respectively. Most neural tissue was located in the posterolateral region. However, the proportion surrounding the anterior part of the prostate increased toward the apex with a median of 6.0% and 7.6% at the base and mid zone regions, respectively, increasing to 11.2% at the apex. CONCLUSIONS: Simple numerical nerve quantification may be insufficient to accurately describe the periprostatic neural distribution. Calculating nerve bundle cross-sectional area confirmed that most neural tissue is in the posterolateral region, although the proportion located anterior increases from base to apex. Thus, higher release of the periprostatic fascia may be indicated toward the apex.

Bicalutamide monotherapy preserves bone mineral density, muscle strength and has significant health-related quality of life benefits for osteoporotic men with prostate cancer.

OBJECTIVES: • To evaluate changes in bone mineral density (BMD), body composition, muscle strength and health-related quality of life (HRQL) during bicalutamide (150 mg) monotherapy in osteoporotic patients with non-metastatic locally advanced prostate cancer. Osteoporosis is prevalent in men presenting with prostate cancer and also a common side effect of treatment with luteinizing hormone-releasing hormone agonists, which are associated with decreased BMD and loss of lean body mass and suppress testosterone, unlike bicalutamide, which results in an increase in serum testosterone and oestrogen levels. PATIENTS AND METHODS: • Forty-two men with non-metastatic locally advanced prostate cancer and osteoporosis (T-score ≤-2.5) were treated with bicalutamide (150 mg) monotherapy. BMD was measured at baseline and 1 year. HRQL was assessed 3-monthly using the RAND 36-Item Health Survey and University of California Los Angeles Prostate Cancer Index questionnaires. Bone turnover markers, liver function tests, prostate-specific antigen, testosterone, oestradiol and haemoglobin were measured at baseline, at 3 weeks and 3-monthly thereafter. Arm anthropometry and dynamometry assessed fat mass, skeletal muscle mass and quadriceps strength. RESULTS: • BMD was maintained (+2.1% lumbar spine, +1.2% total hip and +1.1% forearm). Prostate-specific antigen decreased by 88% at 3 months. Testosterone and oestradiol had increased at 1 year by 58% and 42%, respectively. No increase in bone turnover markers was seen over 1 year. Quadriceps muscle strength was maintained. General and prostate cancer-specific HRQL were maintained throughout the study, with no significant reductions in physical or sexual function. Adverse events included breast pain and gynaecomastia. CONCLUSIONS: • Bicalutamide preserves BMD, muscle strength and HRQL in osteoporotic men with non-metastatic locally advanced prostate cancer. It provides an alternative to medical castration for well informed men at high fracture risk and those wishing to retain physical and sexual activity, with luteinizing hormone-releasing hormone agonists being reserved for those failing to respond or relapsing.

Frequency of zoledronic acid to prevent further bone loss in osteoporotic patients undergoing androgen deprivation therapy for prostate cancer.

OBJECTIVE: To evaluate the efficacy of zoledronic acid (ZA) in osteoporotic patients with prostate cancer receiving either luteinizing hormone-releasing hormone agonists (LHRHA, which accelerate bone loss) or bicalutamide (which preserves bone mineral density, BMD) as androgen-deprivation therapy is the mainstay of treatment for advanced prostate cancer, and many patients are osteoporotic at presentation, with others becoming so on treatment. PATIENTS AND METHODS: Fifty-eight osteoporotic men with non-metastatic prostate cancer were followed for 3 years. Patients were randomly assigned to receive either LHRHA (29) or bicalutamide (29). All received 4 mg ZA 3-monthly for 1 year. BMD was measured by dual energy X-ray absorptiometry at four times: 1 year before ZA; immediately before ZA; after five infusions; and 1 year afterwards. Bone turnover markers (BTMs) were measured at 3-monthly intervals on ZA and 1 year later. All patients had radiography of the thoracolumbar spine at baseline and after ZA. RESULTS: Patients on LHRHA showed a 4.9% decrease in BMD before ZA, a 1.6% increase after ZA and a 3.0% decrease 1 year later, compared to 2.0% increase, 7.8% increase and 1.9% decrease, respectively, in those on bicalutamide. BTMs decreased significantly after ZA. Seven patients (12%) had vertebral fractures at baseline, with none deteriorating at 1 year; two (3.5%) developed mandibular osteonecrosis. CONCLUSION: Before ZA, BMD decreased on LHRHA, but was maintained on bicalutamide. Treatment with 3-monthly ZA increased BMD and suppressed BTMs in osteoporotic patients both on LHRHA and bicalutamide, but to a greater extent in the latter. However, 1 year after the last infusion, BMD declined, suggesting that annual administration is inadequate in these patients. The optimum frequency might be related to BMD at time of bisphosphonate initiation.

Long-term changes in bone mineral density and predicted fracture risk in patients receiving androgen-deprivation therapy for prostate cancer, with stratification of treatment based on presenting values.

OBJECTIVE: To study the long-term effects of androgen-deprivation therapy (ADT) using luteinizing hormone-releasing hormone (LHRH) agonists or antiandrogen therapy with bicalutamide on bone mineral density (BMD) of selected groups of patients with newly diagnosed advanced prostate cancer, stratified by BMD at presentation and to predict alterations in fracture risk. PATIENTS AND METHODS: In all, 618 men with a mean (sd, range) age of 73 (7.1, 49-94) years, initiating ADT for prostate cancer were prospectively recruited and followed from October 1999 to January 2007. BMD was measured by forearm dual-energy X-ray absorptiometry (DEXA) before ADT and repeated annually. Patients with osteoporosis (T-score < or =-2.5) were commenced on bicalutamide; patients with osteopenia (T-score between -1.0 and -2.5) and normal BMD (T-score > -1.0) were commenced on an LHRH agonist. Patients with osteopenia and osteoporosis received calcium and vitamin D supplements. RESULTS: Over 7 years, 1690 DEXA scans were performed. In all, 41% of patients with newly diagnosed prostate cancer were osteoporotic, 39% were osteopenic and 20% had normal BMD. In the normal group, treated with an LHRH agonist, there were significant decreases in BMD (1 year 1.2%; 2 year 3.7%; 3 year 6.5%; 4 year 8.9%; 5 year 9.9%; 6 year 12.7%), which also occurred in the patients with osteopenia with 60% developing osteoporosis after 2 years (1 year 1.8%; 2 year 5.1%; 3 year 8.0%; 4 year 8.2%; 5 year 11.5%; 6 year 14.1%). By contrast, the osteoporotic group maintained BMD (1 year 0.5%; 2 year 0%; 3 year +1.2%; 4 year 0.5%; 5 year 1.7%; 6 year 2.2%). CONCLUSION: Patients treated with an LHRH agonist have significant and sustained decreases in BMD, whereas bicalutamide maintains BMD. We advocate routine assessment of BMD before ADT, with surveillance thereafter.

Enhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View.

CONTEXT: Radical cystectomy (RC) is associated with frequent morbidity and prolonged length of stay (LOS) irrespective of surgical approach. Increasing evidence from colorectal surgery indicates that minimally invasive surgery and enhanced recovery programmes (ERPs) can reduce surgical morbidity and LOS. ERPs are now recognised as an important component of surgical management for RC. However, there is comparatively little evidence for ERPs after robot-assisted radical cystectomy (RARC). Due to the multimodal nature of ERPs, they are not easily validated through randomised controlled trials. OBJECTIVE: To provide a European Association of Urology (EAU) Robotic Urology Section (ERUS) policy on ERPs to guide standardised perioperative management of RARC patients. EVIDENCE ACQUISITION: The guidance was formulated in four phases: (1) systematic literature review of evidence for ERPs in robotic, laparoscopic, and open RC; (2) an online questionnaire survey formulated and sent to ERUS Scientific Working Group members; (3) achievement of consensus from an expert panel using the Delphi process; and (4) a standardised reporting template to audit compliance and outcome designed and approved by the committee. EVIDENCE SYNTHESIS: Consensus was reached in multiple areas of an ERP for RARC. The key principles include patient education, optimisation of nutrition, RARC approach, standardised anaesthetic, analgesic, and antiemetic regimens, and early mobilisation. CONCLUSIONS: This consensus represents the views of an expert panel established to advise ERUS on ERPs for RARC. The ERUS Scientific Working Group recognises the role of ERPs and endorses them as standardised perioperative care for patients undergoing RARC. ERPs in robotic surgery will continue to evolve with technological and pharmaceutical advances and increasing understanding of the role of surgery-specific ERPs. PATIENT SUMMARY: There is currently a lack of high-level evidence exploring the benefits of enhanced recovery programmes (ERPs) in patients undergoing robot-assisted radical cystectomy (RARC). We reported a consensus view on a standardised ERP specific to patients undergoing RARC. It was formulated by experts from high-volume RARC hospitals in Europe, combining current evidence for ERPs with experts' knowledge of perioperative care for robotic surgery.

Chemical composition of gases surgeons are exposed to during endoscopic urological resections.

OBJECTIVES: To identify any potentially harmful chemical constituents of the gaseous plume produced from urological endoscopic diathermy. METHODS: Chemical analysis was performed on the gaseous plume produced from prostatic resections and vaporizations using gas chromatography with mass spectroscopy and high-performance liquid chromatography using ultraviolet and visible light detection. In addition, carbon monoxide levels were analyzed using a portable catalytic flammable gas sensor. RESULTS: This study identified a cocktail of volatile organic hydrocarbons produced during these procedures, some of which are known carcinogens. The most significant finding being high levels of carbon monoxide. CONCLUSIONS: From this preliminary study, we advocate the use of smoke evacuator systems for all urologists regularly performing these procedures, and suggest that further research is required to investigate potential long-term complications to the urologist.

Testosterone recovery and changes in bone mineral density after stopping long-term luteinizing hormone-releasing hormone analogue therapy in osteoporotic patients with prostate cancer.

OBJECTIVE: To investigate the rate of testosterone recovery and changes in bone mineral density in patients found to be osteoporotic while receiving luteinizing hormone-releasing hormone (LHRH) analogues after changing to antiandrogen monotherapy in an attempt to reduce further demineralization. PATIENTS AND METHODS: Fifteen patients receiving LHRH analogue therapy for > or = 1 year were identified as osteoporotic by distal forearm dual X-ray densitometry. They were then converted to antiandrogen monotherapy, and prostate specific-antigen (PSA) and total testosterone monitored at 3-monthly intervals. The forearm densitometry was repeated at 1 year. RESULTS: All patients had some testosterone recovery; the mean (range) duration to initial detectable testosterone was 12.8 (6-22) months. Six patients had a normal testosterone level after a mean of 17.5 (14-30) months. In the year after stopping LHRH analogue therapy the mean bone mineral density (t-score) decreased by 7.2%. CONCLUSIONS: Osteoporotic patients, after stopping LHRH analogues, continue to have suppressed levels of testosterone which have a detrimental effect on bone mineral density. We therefore would not advocate conversion to antiandrogen monotherapy to improve bone density, and suggest alternative therapeutic intervention e.g. bisphosphonate therapy, for these patients.