Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeons.

PURPOSE: With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy. MATERIALS AND METHODS: We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring and credentialing. RESULTS: Proctoring is an essential mechanism for robot assisted radical prostatectomy institutional credentialing and should be a prerequisite for granting unrestricted privileges on the robot. This should be differentiated from preceptoring, wherein the expert is directly involved in hands-on training. Advanced technology has opened new avenues for long-distance observation through teleproctoring. Although the medicolegal implications of an active surgical intervention by a proctor are not clearly defined, the role as an observer should grant immunity from malpractice liability. CONCLUSIONS: The implementation of guidelines and proctoring recommendations is necessary to protect surgeons, proctors, institutions and, above all, the patients who are associated with the institutional introduction of a robot assisted radical prostatectomy program. With no current guidelines we anticipate this article will serve as a catalyst of interorganizational discussion to initiate regulatory oversight of surgeon certification and proctorship.

Can SUVmax values of Ga-68-PSMA PET/CT scan predict the clinically significant prostate cancer?

PURPOSE: The intensity of prostate-specific membrane antigen (PSMA) expression increases as the tumor grade increases and the uptake of Ga-68-PSMA is higher in high-grade tumors. The aim of the present study was to evaluate the correlation of preoperative tracer uptake of primary tumor to Gleason Score in patients who underwent prostatectomy. PATIENTS AND METHODS: We retrospectively evaluated 141 patients who had Ga-68-PSMA positron emission tomography/computed tomography (PET/CT) imaging and who underwent prostatectomy. All patients had a diagnosis of prostate cancer on the basis of 10-24 cores transrectal ultrasound-guided biopsy (TRUS-Bx). Histological assessment was performed according to the New Contemporary Prostate Cancer Grading System. All patients had a prostate-specific antigen (PSA) level measurement within maximum of 28 days before Ga-68-PSMA PET/CT. Region of interests were drawn manually around the prostate gland, avoiding the bladder activity, to calculate the maximum standardized uptake values (SUVmax) values. RESULTS: The median PSA values for all patients were 10.0 ng/ml. PSA values for low-risk patients were significantly lower than those of high-risk patients (P<0.001). There were 41.1% upgrades and 7.8% downgrades following prostatectomy in terms of Grade Groups. According to the final pathology reports, 21% (n=16) of patients moved from a low-risk level (grade groups 1+2) to a high-risk level (grade groups 3+4+5). The median SUVmax value was 8.8, ranging from 2.1 to 62.4. There was a strong correlation between SUVmax values and grade groups (Pearson ρ=0.66) (P<0.001). The mean SUVmax values of high-risk patients were significantly higher than those of low-risk patients (18.9±12.1 vs. 7.16±6.2, respectively) (P<0.001). Receiver operation characteristic curve analysis of SUVmax at the cut-off value of 9.1 showed a high sensitivity (78%) and specificity (81%) for detection of high risk disease. CONCLUSION: SUVmax values correlate significantly with the grade groups of the primary tumor. The intraprostatic accumulation sites may predict clinically significant cancer and potentially serve as a target for biopsy sampling in conjunction with mpMRI in selected patients.

The role of PSMA PET/CT imaging in restaging of prostate cancer patients with low prostate-specific antigen levels.

INTRODUCTION: Prostate-specific membrane antigen (PSMA) is increasingly being recognized as a novel target for the PET imaging of prostate cancer (PCa) and Ga-DKFZ-11 (Ga-PSMA) has been suggested as a novel tracer for detection of PCa relapses and metastases. The aim of this study was to evaluate the diagnostic value of PSMA PET/CT in the diagnosis of recurrent PCa with low prostate-specific antigen (PSA) levels. PATIENTS AND METHODS: We carried out a retrospective analysis of patients who underwent PSMA PET/CT from November 2013 to December 2014 in our department. Among these patients, 50 out of 178 who had increasing PSA levels (<5 ng/ml) and did not have known metastasis were included in this study. RESULTS: Patients had an average PSA of 1.41 ng/ml. A total of 29 patients (58%) showed at least one positive lesion. PET positivity rates of 31% (n=4), 54% (n=13), and 88% (n=14) were observed in patients with a PSA level of less than 0.2, 0.2-2, and 2-5 ng/ml, respectively. A positive correlation was observed between positivity rate and Gleason scores and blood PSA levels. Verification was performed in 46 patients, with biopsy (n=3) and follow-up, and conventional imaging studies at the time of the PET/CT or during follow-up with a mean period of 10.6±3.3 months and ranged from 3.8 to 16.4 months. According to patient-based analysis of 46 cases, 57% of patients had true positive, 24% of patients had true negative, 2% of patients had false positive, an 18% of patients had false-negative findings. A sensitivity of 76.47% (95% confidence interval: 58.83-89.25%) and a specificity of 91.67% (95% confidence interval: 61.52-99.79%) were found. CONCLUSION: PET/CT with Ga-PSMA is a valuable tool for assessing recurrence of PCa with a high sensitivity in patients who have PSA levels between 0.2 and 5 ng/ml. In addition, this study suggests that PSMA PET/CT can be used in patients with very low (<0.2 ng/ml) but increasing PSA levels, which, in many cases, may influence further clinical management.

Adult clear cell sarcoma of the kidney: a case report.

BACKGROUND: Clear cell sarcoma of the kidney (CCSK) in adults is extremely rare. Optimal treatment of adult patients with CCSK remains unclear. CASE PRESENTATION: A 22-year-old man presented with a 2-month history of left flank pain. A color duplex sonography revealed a hypervascular, heterogeneous renal mass. Abdominal and pelvic computerized tomography showed a heterogeneous mass originating from the lower pole of the left kidney and infiltrating to the psoas muscle. Further evaluation including bone scan did not demonstrate any evidence of metastases. A left radical nephrectomy with hilar lymphadenectomy through an intraperitoneal approach with an anterior subcostal incision was performed. The histopathological diagnosis of the mass was a clear cell sarcoma of the kidney. No lymph node metastases were found. Concomitant chemo-radiotherapy was performed. Therapy-related serious side effects were not observed. There was no evidence of local recurrence or metastases during the following twenty-four months after therapy. CONCLUSION: We believe that the combination therapy is efficacious for preventing the local recurrence and distant metastases. Accurate diagnosis is very important and therapy must also include doxorubicin regardless of the disease stage in adult patients with CCSK.

Differences in ureteroscopic stone treatment and outcomes for distal, mid-, proximal, or multiple ureteral locations: the Clinical Research Office of the Endourological Society ureteroscopy global study.

BACKGROUND: Ureteroscopy has traditionally been the preferred approach for treatment of distal and midureteral stones, with shock wave lithotripsy used for proximal ureteral stones. OBJECTIVE: To describe the differences in the treatment and outcomes of ureteroscopic stones in different locations. DESIGN, SETTING, AND PARTICIPANTS: Prospective data were collected by the Clinical Research Office of the Endourological Society on consecutive patients treated with ureteroscopy at centres around the world over a 1-yr period. INTERVENTION: Ureteroscopy was performed according to study protocol and local clinical practice guidelines. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Stone location, treatment details, postoperative outcomes, and complications were recorded. Pearson's chi-square analysis and analysis of variance were used to compare outcomes among the different stone locations. RESULTS AND LIMITATIONS: Between January 2010 and October 2012, 9681 patients received ureteroscopy treatment for stones located in the proximal ureter (n=2656), midureter (n=1980), distal ureter (n=4479), or multiple locations (n=440); location in 126 patients was not specified. Semirigid ureteroscopy was predominantly used for all stone locations. Laser and pneumatic lithotripsy were used in the majority of cases. Stone-free rates were 94.2% for distal ureter locations, 89.4% for midureter locations, 84.5% for proximal ureter locations, and 76.6% for multiple locations. For the proximal ureter, failure and retreatment rates were significantly higher for semirigid ureteroscopy than for flexible ureteroscopy. A low incidence of intraoperative complications was reported (3.8-7.7%). Postoperative complications occurred in 2.5-4.6% of patients and varied according to location, with the highest incidence reported for multiple stone locations. Limitations include short-term follow-up and a nonuniform treatment approach. CONCLUSIONS: Ureteroscopy for ureteral stones resulted in good stone-free rates with low morbidity. PATIENT SUMMARY: This study shows that patients who have ureteral stones can be treated successfully with ureteroscopy with a low rate of complications for the patient.