Robot-assisted radical cystectomy and intracorporeal neobladder formation: on the way to a standardized procedure.

BACKGROUND: Robot-assisted radical cystectomy (RARC) with intracorporeal diversion has been shown to be feasible in a few centers of excellence worldwide, with promising functional and oncologic outcomes. However, it remains unknown whether the complexity of the procedure allows its duplication in other non-pioneer centers. We attempt to address this issue by presenting our cumulative experience with RARC and intracorporeal neobladder formation. METHODS: We retrospectively identified 62 RARCs in 50 men and 12 women (mean age 63.6 years) in two tertiary centers. Intracorporeal Studer neobladders were created, duplicating the steps of standard open surgery. Perioperative and postoperative variables and complications were analyzed using standardized tools. Functional and oncological results were assessed. RESULTS: The mean operative time was 476.9 min (range, 310 to 690) and blood loss was 385 ml (200 to 800). The mean hospital stay was 16.7 (12 to 62) days with no open conversion. Perioperative complications were grade II in 15, grade III in 11, and grade IV in 5 patients. The mean nodal yield was 22.9 (8 to 46). Positive margins were found in in 6.4%. The 90- and 180-day mortality rates were 0% and 3.3%. The average follow-up was 37.3 months (3 to 52). Continence was achieved in 88% of patients. The cancer-specific survival rate and overall survival rate were 84% and 71%, respectively. CONCLUSIONS: A RARC with intracorporeal neobladder creation is safe and reproducible in 'non-pioneer' tertiary centers with robotic expertise with acceptable operative time and complications. Further standardization of RARC with intracorporeal diversion is a prerequisite for its widespread use.

Robot-assisted radical cystectomy and intracorporeal urinary diversion - safe and reproducible?

INTRODUCTION: Robot-assisted radical cystectomy (RARC) plus intracorporeal urinary diversion is feasible. Few centers worldwide demonstrated comparable functional and oncologic outcomes. We reported a large series of RARC and intracorporeal diversion to assess its feasibility and reproducibility. MATERIAL AND METHODS: We identified 101 RARCs in 82 men and 19 women (mean age 68.3 years) from October 2009 to October 2014. The patients underwent RARC and pelvic lymphadenectomy followed by intracorporeal urinary diversion (ileal conduit/ neobladder). Out of the 101 patients, 28 (27.7%) received intracorporeal ileal conduits and 73 (72.3%) intracorporeal neobladders. Studer pouch was performed in all the patients who underwent intracorporeal neobladder formation. Perioperative, functional and oncologic results including CSS and OS are reported. RESULTS: Mean operative time was 402.3 minutes (205-690) and blood loss was 345.3 ml (50-1000). The mean hospital stay was 17.1 days (5-62). All the surgeries were completed with no open conversion. Minor complications (Grade I and II) were reported in 27.7% of patients while major complications (grade III and above) were reported in 36.6% of patients. The mean nodal yield was 20.6 (0-46). Positive ureteric margins were found in 8.9% of patients. The average follow-up was 27.5 months (1-52). Daytime continence could be achieved in 89.2% of patients who underwent intracorporeal neobladder. The 3-year cancer specific survival (CSS) and overall survival (OS) was 80.2% and 69.8% respectively. CONCLUSIONS: RARC with intracorporeal diversion is safe and reproducible in 'non-pioneer' tertiary centers with robotic expertise having acceptable operative time and complications as well as comparable functional and oncologic outcomes.

Postchemotherapy laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell tumors infiltrating the great vessels.

BACKGROUND AND PURPOSE: Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is an alternative in patients with metastatic nonseminomatous germcell tumors (NSGCT) necessitating resection of residuals postchemotherapy. With the advancement of laparoscopic vascular surgery, prospective management of the great vessels has become feasible and safe. We present our experience with L-RPLND in NSGCT residuals with significant vascular involvement necessitating intracorporeal reconstruction. PATIENTS AND METHODS: We have retrospectively identified 19 NSGCT patients (mean age 27 years) who presented with residuals postchemotherapy. A bilateral L-RPLND was performed in all men. Infiltration of the great vessels was confirmed intraoperatively. Prospective vascular control and temporary clamping was performed in all cases. The vessel wall was reconstructed using vascular surgery techniques. All patients had at least clinical stages of IIA or higher. Follow-up was obtained in all. RESULTS: There were no conversions to open surgery. The mean size of the residuals after chemotherapy was 3.87 cm (1.5-9.7 cm). The mean blood loss was 310 mL (50-1000 mL). Mean hospital stay was 6 days (3-9 days). There were no perioperative complications exceeding grade II according to the Clavien-Dindo classification. Distant or in-field recurrence (mean observational period 18 months) did not develop in any patient. CONCLUSION: Laparoscopic RPLND may be considered a safe alternative concept for the management of post-chemotherapy NSGCT residuals involving the great vessels. Bilateral L-RPLND in patients with vascular infiltration is feasible and reproducible when laparoscopic vascular surgery can be reliably handled. All standard principles of open surgery are respected, and initial oncologic results are promising.

Stepwise application of urine markers to detect tumor recurrence in patients undergoing surveillance for non-muscle-invasive bladder cancer.

BACKGROUND: The optimal use of urine markers in the surveillance of non-muscle-invasive bladder cancer (NMIBC) remains unclear. Aim of the present study was to investigate the combined and stepwise use of the four most broadly available urine markers to detect tumor recurrence in patients undergoing surveillance of NMIBC. PATIENTS AND METHODS: 483 patients with history of NMIBC were included. Cytology, UroVysion, fluorescence in situ hybridization (FISH), immunocytology (uCyt+), and NMP22 ELISA were performed before surveillance cystoscopy. Characteristics of single tests and combinations were assessed by contingency analysis. RESULTS: 128 (26.5%) patients had evidence of tumor recurrence. Sensitivities and negative predictive values (NPVs) of the single tests ranged between 66.4-74.3 and 82.3-88.2%. Two-marker combinations showed sensitivities and NPVs of 80.5-89.8 and 89.5-91.2%. A stepwise application of the two-test combinations with highest accuracy (cytology and FISH; cytology and uCyt+; uCyt+ and FISH) showed NPVs for high-risk recurrences (G3/Cis/pT1) of 98.8, 98.8, and 99.1%, respectively. CONCLUSIONS: Combinations of cytology, FISH, immunocytology, and NMP22 show remarkable detection rates for recurrent NMIBC. Stepwise two-test combinations of cytology, FISH, and immunocytology have a low probability of missing a high-risk tumor. The high sensitivities may justify the use of these combinations in prospective studies assessing the use of urine markers to individualize intervals between cystoscopies during follow-up.