Propensity-Score Matched Analysis Between Extraperitoneal Single Port and Intraperitoneal Multiport Radical Prostatectomy: A Single-Institutional Experience.

OBJECTIVE: To compare the perioperative results and intermediate-term functional outcomes of single port and multiport robotic-assisted laparoscopic prostatectomy by using a propensity-score analysis. MATERIALS AND METHODS: We evaluated all patients who underwent robotic prostatectomy by 3 urologic surgeons at our institution between January 2019 and October 2020. Demographic, intraoperative, and postoperative data were collected and assessed. Patients were matched based on body mass index, Gleason group, and prostate volume using the optimal matching method. RESULTS: Overall, 98 and 165 patients underwent single port and multiport robotic prostatectomy, respectively. Following propensity-score matching, 98 multiport cases were matched 1:1 to single port cases. The median operative time was lower for multiport (111.5 vs 147.0 minutes, P = .0000). Single port had a lower median estimated blood loss (50.0 vs 75.0 mL, P = .0006), pain score on postoperative day 0 (1.0 vs 2.0, P = .0004), opioid use at postoperative day 1 (0.0 [IQR 0.0-5.0] vs 0.0 MME [IQR 0.0-7.5], P = .0058), cumulative opioid use (2.0 vs 7.0 MME, P = .0008), and lymph node yield (4.0 vs 7.0 nodes, P = .0051). Single port had a greater percentage of men regain full erectile function by 6 months (23.8% vs 4.8%, P = .002). CONCLUSION: The single port robotic system is a safe option for localized prostate cancer treatment, offering superior pain control and comparable perioperative results and intermediate-term functional outcomes compared to the multiport robotic approach.

Single-Port Robotic Radical Cystectomy with Intracorporeal Bowel Diversion: Initial Experience and Review of Surgical Outcomes.

Introduction and Objective: Scant literature is available on surgical outcomes of radical cystectomies on the new single-port (SP) system. This study compares short-term outcomes in patients undergoing radical cystectomy with those undergoing intracorporeal urinary diversion (ICUD) on the multiport (MP) vs SP platform. Methods: This institutional review board approved study used a prospective cystectomy database and nonparametric testing including chi-squared, Mann-Whitney U, and Fisher exact tests to analyze all variables stratified by surgical approach. Results: Thirty-four patients underwent radical cystectomy with ICUD from September 1, 2019, to February 8, 2021. Twenty patients were in the MP cohort, whereas 14 were in the SP group. Table 1 presents the demographics of both groups and shows no statistically significant differences. Intra- and postoperative as well as pathology data are given in Table 2. Patients in the SP group had less narcotic use (MP: 25 morphine milligram equivalent [MME] vs SP: 11.5 MME, p = 0.047) and shorter return of bowel function (MP: 3 days vs SP: 2 days, p = 0.032). Operative times were similar between both groups despite having fewer patients undergoing ileal conduit (MP: 85% vs SP: 50%, p = 0.027) in the SP group. In Table 3, we list the early short-term postoperative follow-up data for each group that showed no significant differences between the two groups with an average follow-up of 4.9 months for MP and 4.4 months for SP. Conclusions: Our initial experience with SP robotic cystectomy and ICUD appears to be safe and an effective alternative to MP cystectomies. A learning curve was involved but the overall transition from MP to SP was smooth. Operative times were similar despite fewer patients undergoing ileal diversion, shorter return of bowel function, and less narcotic use in the SP group. Further studies including longer follow-ups with multi-institutional data are underway.

Ureteral Rest is Associated With Improved Outcomes in Patients Undergoing Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures.

OBJECTIVES: To evaluate the effect of ureteral rest on outcomes of robotic ureteral reconstruction. METHODS: We retrospectively reviewed all patients who underwent robotic ureteral reconstruction of proximal and/or middle ureteral strictures in our multi-institutional database between 2/2012-03/2019 with ≥12 months follow-up. All patients were recommended to undergo ureteral rest, which we defined as the absence of hardware (ie. double-J stent or percutaneous nephroureteral tube) across a ureteral stricture ≥4 weeks prior to reconstruction. However, patients who refused percutaneous nephrostomy tube placement did not undergo ureteral rest. Perioperative outcomes were compared after grouping patients according to whether or not they underwent ureteral rest. Continuous and categorical variables were compared using Mann-Whitney U and 2-tailed chi-squared tests, respectively; P <.05 was considered significant. RESULTS: Of 234 total patients, 194 (82.9%) underwent ureteral rest and 40 (17.1%) did not undergo ureteral rest prior to ureteral reconstruction. Patients undergoing ureteral rest were associated with a higher success rate compared to those not undergoing ureteral rest (90.7% versus 77.5%, respectively; P = .027). Also, patients undergoing ureteral rest were associated with lower estimated blood loss (50 versus 75 milliliters, respectively; p<0.001) and less likely to undergo buccal mucosa graft ureteroplasty (20.1% versus 37.5%, respectively; p=0.023). CONCLUSIONS: Implementing ureteral rest prior to ureteral reconstruction may allow for stricture maturation and is associated higher surgical success rates, lower estimated blood loss, and decreased utilization of buccal mucosa graft ureteroplasty.

Intermediate-term outcomes after robotic ureteral reconstruction for long-segment (≥4 centimeters) strictures in the proximal ureter: A multi-institutional experience.

PURPOSE: To report our intermediate-term, multi-institutional experience after robotic ureteral reconstruction for the management of long-segment proximal ureteral strictures. MATERIALS AND METHODS: We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all patients who underwent robotic ureteral reconstruction for long-segment (≥4 centimeters) proximal ureteral strictures between August 2012 and June 2019. The primary surgeon determined the specific technique to reconstruct the ureter at time of surgery based on the patient's clinical history and intraoperative findings. Our primary outcome was surgical success, which we defined as the absence of ureteral obstruction on radiographic imaging and absence of obstructive flank pain. RESULTS: Of 20 total patients, 4 (20.0%) underwent robotic ureteroureterostomy (RUU) with downward nephropexy (DN), 2 (10.0%) underwent robotic ureterocalycostomy (RUC) with DN, and 14 (70.0%) underwent robotic ureteroplasty with buccal mucosa graft (RU-BMG). Median stricture length was 4 centimeters (interquartile range [IQR], 4-4; maximum, 5), 6 centimeters (IQR, 5-7; maximum, 8), and 5 centimeters (IQR, 4-5; maximum, 8) for patients undergoing RUU with DN, RUC with DN, and RU-BMG, respectively. At a median follow-up of 24 (IQR, 14-51) months, 17/20 (85.0%) cases were surgically successful. Two of four patients (50.0%) who underwent RUU with DN developed stricture recurrences within 3 months. CONCLUSIONS: Long-segment proximal ureteral strictures may be safely and effectively managed with RUC with DN and RU-BMG. Although RUU with DN can be utilized, this technique may be associated with a higher failure rate.

A Multi-Institutional Experience With Robotic Ureteroplasty With Buccal Mucosa Graft: An Updated Analysis of Intermediate-Term Outcomes.

OBJECTIVE: To update our prior multi-institutional experience with robotic ureteroplasty with buccal mucosa graft and analyze our intermediate-term outcomes. Although our previous multi-institutional report provided significant insight into the safety and efficacy associated with robotic ureteroplasty with buccal mucosa graft, it was limited by small patient numbers. METHODS: We retrospectively reviewed our multi-institutional database to identify all patients who underwent robotic ureteroplasty with buccal mucosa graft between October 2013 and March 2019 with ≥12 months follow up. Indication for surgery was a complex proximal and/or middle ureteral stricture not amenable to primary excision and anastomosis secondary to stricture length or peri-ureteral fibrosis. Surgical success was defined as the absence of obstructive flank pain and ureteral obstruction on functional imaging. RESULTS: Of 54 patients, 43 (79.6 %) patients underwent an onlay, and 11 (20.4%) patients underwent an augmented anastomotic robotic ureteroplasty with buccal mucosa graft. Eighteen of 54 (33.3%) patients previously failed a ureteral reconstruction. The median stricture length was 3.0 (IQR 2.0-4.0, range 1-8) centimeters. There were 3 of 54 (5.6%) major postoperative complications. The median length of stay was 1.0 (IQR 1.0-3.0) day. At a median follow-up of 27.5 (IQR 21.3-38.0) months, 47 of 54 (87.0%) cases were surgically successful. Stricture recurrences were diagnosed ≤2 months postoperatively in 3 of 7 (42.9%) patients, and ≥10 months postoperatively in 4 of 7 (57.1%) patients. CONCLUSION: Robotic ureteroplasty with buccal mucosa graft is associated with low peri-operative morbidity and excellent intermediate-term outcomes.

Robotic Ureteral Reconstruction in Patients with Radiation-Induced Ureteral Strictures: Experience from the Collaborative of Reconstructive Robotic Ureteral Surgery.

Objectives: Management of radiation-induced ureteral stricture (RIUS) is complex, requiring chronic drainage or morbid definitive open reconstruction. Herein, we report our multi-institutional comprehensive experience with robotic ureteral reconstruction (RUR) in patients with RIUSs. Patients and Methods: In a retrospective review of our multi-institutional RUR database between January 2013 and January 2020, we identified patients with RIUSs. Five major reconstruction techniques were utilized: end-to-end (anastomosing the bladder to the transected ureter) and side-to-side (anastomosing the bladder to an anterior ureterotomy proximal to the stricture without ureteral transection) ureteral reimplantation, buccal or appendiceal mucosa graft ureteroplasty, appendiceal bypass graft, and ileal ureter interposition. When necessary, adjunctive procedures were performed for mobility (i.e., psoas hitch) and improved vascularity (i.e., omental wrap). Outcomes of surgery were determined by the absence of flank pain (clinical success) and absence of obstruction on imaging (radiological success). Results: A total of 32 patients with 35 ureteral units underwent RUR with a median stricture length of 2.5 cm (interquartile range [IQR] 2-5.5). End-to-end and side-to-side reimplantation techniques were performed in 21 (60.0%) and 8 (22.9%) RUR cases, respectively, while 4 (11.4%) underwent an appendiceal procedure. One patient (2.9%) required buccal mucosa graft ureteroplasty, while another needed an ileal ureter interposition. The median operative time was 215 minutes (IQR 177-281), estimated blood loss was 100 mL (IQR 50-150), and length of stay was 2 days (IQR 1-3). One patient required repair of a small bowel leak. Another patient died from a major cardiac event and was excluded from follow-up calculations. At a median follow-up of 13 months (IQR 9-22), 30 ureteral units (88.2%) were clinically and radiologically effective. Conclusion: RUR can be performed in patients with RIUSs with excellent outcomes. Surgeons must be prepared to perform adjunctive procedures for mobility and improved vascularity due to poor tissue quality. Repeat procedures for RIUSs heighten the risk of necrosis and failure.

Ureteral Reimplantation via Robotic Nontransecting Side-to-Side Anastomosis for Distal Ureteral Stricture.

Objective: To describe a novel technique of ureteral reimplantation through robotic nontransecting side-to-side anastomosis. Although the standard approach to ureteroneocystostomy has a high rate of success, it involves transection of the ureter that may impair vascularity and contribute to recurrent strictures. Our method seeks to maximally preserve distal ureteral blood flow that may reduce this risk. Materials and Methods: We retrospectively reviewed a multi-institutional ureteral reconstruction database to identify patients who underwent this operation between 2014 and 2018, analyzing perioperative and postoperative outcomes. Results: Our technique was utilized in 16 patients across three U.S. academic institutions. Median operative time and estimated blood loss were 178 minutes (interquartile range [IQR] 150-204) and 50 mL (IQR 38-100), respectively. The median length of stay was 1 day (IQR 1-2). No intraoperative complications or postoperative complications with Clavien score ≥3 were reported. Postoperatively, 15 of 16 (93.8%) patients reported clinical improvement in flank pain, and all patients who underwent follow-up imaging had radiographic improvement with decrease in hydronephrosis at a median follow-up of 12.5 months. Conclusions: Ureteral reimplantation through a robotic nontransecting side-to-side anastomosis is a feasible and effective operation for distal ureteral stricture that may have advantages over the standard of care transecting ureteroneocystostomy.

Postoperative Complications After Robotic Partial Nephrectomy.

Objectives: To assess the incidence of postoperative arterial malformation (AM) and urine leak/urinoma (UL) after robotic partial nephrectomy (RPN) in a contemporary series and to evaluate risk factors for these complications. Materials and Methods: All RPNs were queried from Institutional Review Board-approved retrospective and prospective nephrectomy databases. Demographics, perioperative variables, and postoperative complications were collected. Differences between cohorts were analyzed using univariate analysis. Postoperative complications were graded using the Clavien-Dindo system. UL was defined in the context of signs and symptoms of a collection with supporting evidence of urine collection through drainage or aspiration. AM was identified based on postoperative imaging indicative of arteriovenous fistula or pseudoaneurysm and/or requirement for selective embolization. Predictors of AM and UL were assessed by univariate analysis. Results: A total of 395 RPNs were performed by four urologists between January 2014 and October 2018. Tumor complexity, defined by nephrometry score, was significantly greater in the prospective cohort (p = 0.01). Overall incidence of postoperative complications was 5.6% with cohort-specific incidences of 5.3% and 5.8%. The retrospective cohort had a greater percentage of complications classified as ≥IIIa: 8/13 (61.5%) vs 2/8 (25%). Overall incidence of AM was 2.3% with cohort-specific incidence of 3.1% (7/225) vs 1.1% (2/170). Overall incidence of UL was 0.25% with cohort-specific incidence of 0.55% (1/225) and 0.0% (0/170). The difference in incidence of both complications between cohorts was significant (p < 0.05). No significant predictors for AM were identified. Conclusions: The incidence of postoperative complications after RPN remains low (5.3% vs 5.8%, overall: 5.6%). UL and AM are becoming rarer with experience, despite increasing surgical complexity (0.55% vs 0%, 3.1% vs 1.1%).

Multi-institutional Experience Comparing Outcomes of Adult Patients Undergoing Secondary Versus Primary Robotic Pyeloplasty.

OBJECTIVE: To describe surgical techniques and peri-operative outcomes with secondary robotic pyeloplasty (RP), and compare them to those of primary RP. METHODS: We retrospectively reviewed our multi-institutional, collaborative of reconstructive robotic ureteral surgery (CORRUS) database for all consecutive patients who underwent RP between April 2012 and September 2019. Patients were grouped according to whether they underwent a primary or secondary pyeloplasty (performed for a recurrent stricture after previously failed pyeloplasty). Perioperative outcomes and surgical techniques were compared using nonparametric independent sample median tests and chi-square tests; P < .05 was considered significant. RESULTS: Of 158 patients, 28 (17.7%) and 130 (82.3%) underwent secondary and primary RP, respectively. Secondary RP, compared to primary RP, was associated with a higher median estimated blood loss (100.0 vs 50.0 milliliters, respectively; P < .01) and longer operative time (188.0 vs 136.0 minutes, respectively; P = .02). There was no difference in major (Clavien >2) complications (P = .29). At a median follow-up of 21.1 (IQR: 11.8-34.7) months, there was no difference in success between secondary and primary RP groups (85.7% vs 92.3%, respectively; P = .44). Buccal mucosa graft onlay ureteroplasty was performed more commonly (35.7% vs 0.0%, respectively, P < .01) and near-infrared fluorescence imaging with indocyanine green was utilized more frequently (67.9% vs 40.8%, respectively; P < .01) for secondary vs primary repair. CONCLUSION: Although performing secondary RP is technically challenging, it is a safe and effective method for recurrent ureteropelvic junction obstruction after a previously failed pyeloplasty. Buccal mucosa graft onlay ureteroplasty and utilization of near-infrared fluorescence with indocyanine green may be particularly useful in the re-operative setting.