Blinded review of archival radical prostatectomy specimens supports that contemporary Gleason score 6 prostate cancer lacks metastatic potential.

BACKGROUND: Retrospective identification of Gleason pattern 4 in metastatic Gleason score 3 + 3 = 6 (GS6) radical prostatectomy (RP) specimens has suggested true GS6 prostate cancer (CaP) lacks metastatic potential. However, pathologist awareness of study design and metastasis outcomes at the time of RP review might have introduced upgrading bias. We used pathologist-blinded methodology for unbiased characterization of metastasis rates for contemporarily defined pathologic GS6 (pGS6) CaP. METHODS: An institutional RP database was queried to identify pGS6 patients with metastasis or concern for micrometastasis based on: 1) biochemical failure (BF) despite negative surgical margins or 2) incomplete biochemical response to salvage/adjuvant radiation. RP specimens were regraded independently by two genitourinary pathologists blinded to study aims or clinical outcomes. Additional blinding was performed by random inclusion of pGS6 control specimens from BF-free patients. Only upgrading identified independently by both pathologists was considered. RESULTS: Among 451 pGS6 patients identified, none had synchronous lymph node metastases and 43/451 (10%) suffered BF. Two patients (0.4%) developed metachronous metastasis during a 110-month median follow-up for BF patients. Both metastatic cases had Gleason pattern 4 on blinded RP review, as did 88% of cases with concern for micrometastasis versus 38% of control cases (P = 0.02). All BF patients (29/29) undergoing postoperative radiation had a complete biochemical response or Gleason pattern 4 on blinded RP review. CONCLUSIONS: Unbiased pathologist review of archival RP specimens supports absent metastatic potential for contemporarily defined GS6 CaP. Reduced postoperative monitoring is appropriate for pGS6, but may require pathology review to confirm absent Gleason pattern 4.

American Confederation of Urology (CAU) experience in minimally invasive partial nephrectomy.

PURPOSE: To describe the perioperative and oncology outcomes in a series of laparoscopic or robotic partial nephrectomies (PN) for renal tumors treated in diverse institutions of Hispanic America from the beginning of their minimally invasive (MI) PN experience through December 2014. METHODS: Seventeen institutions participated in the CAU generated a MI PN database. We estimated proportions, medians, 95 % confidence intervals, Kaplan-Meier curves, multivariate logistic and Cox regression analyses. Clavien-Dindo classification was used. RESULTS: We evaluated 1501 laparoscopic (98 %) or robotic (2 %) PNs. Median age: 58 years. Median surgical time, warm ischemia and intraoperative bleeding were 150, 20 min and 200 cc. 81 % of the lesions were malignant, with clear cell histology being 65 % of the total. Median maximum tumor diameter is 2.7 cm, positive margin is 8.2 %, and median hospitalization is 3 days. One or more postoperative complication was recorded in 19.8 % of the patients: Clavien 1: 5.6 %; Clavien 2: 8.4 %; Clavien 3A: 1.5 %; Clavien 3B: 3.2 %; Clavien 4A: 1 %; Clavien 4B: 0.1 %; Clavien 5: 0 %. Bleeding was the main cause of a reoperation (5.5 %), conversion to radical nephrectomy (3 %) or open partial nephrectomy (6 %). Transfusion rate is 10 %. In multivariate analysis, RENAL nephrometry score was the only variable associated with complications (OR 1.1; 95 % CI 1.02-1.2; p = 0.02). Nineteen patients presented disease progression or died of disease in a median follow-up of 1.37 years. The 5-year progression or kidney cancer mortality-free rate was 94 % (95 % CI 90, 97). Positive margins (HR 4.98; 95 % CI 1.3-19; p = 0.02) and females (HR 5.6; 95 % CI 1.7-19; p = 0.005) were associated with disease progression or kidney cancer mortality after adjusting for maximum tumor diameter. CONCLUSION: Laparoscopic PN in these centers of Hispanic America seem to have acceptable perioperative complications and short-term oncologic outcomes.

Minimally invasive cytoreductive nephrectomy: a multi-institutional experience.

PURPOSE: To analyze the functional and oncologic outcomes of minimally invasive cytoreductive nephrectomy (CN) in three high-volume cancer centers. PATIENTS AND METHODS: Three prospectively maintained, IRB-approved kidney surgery databases were queried from three high-volume cancer centers. All patients who underwent minimally invasive surgery (laparoscopic, hand-assisted laparoscopic, or robotic) partial or radical CN with existing measurable extra-renal metastatic disease between May 2001 and May of 2013 were included in this analysis. RESULTS: We identified 120 patients who underwent minimally invasive CN for metastatic renal cell carcinoma. Most of the surgeries were radical (93.3 %) and performed laparoscopically (96.6 %). Median operative time was 210 min, with a median estimated blood loss of 150 cc, and 11 (9.2 %) patients received blood transfusions. Four (3.3 %) patients were converted to open surgery due to locally advanced disease and/or bleeding. Postoperative complications were seen in 28 (23.3 %) patients, of which 20 (71.4 %) were classified as minor (Clavien-Dindo I-II). The median survival of the entire cohort was 25.7 months, with a 3-year survival rate of 35 %. Multivariate analysis indicated that only hypertension, brain metastasis, and pT stage were independently associated with worse overall survival (HR > 1). CONCLUSIONS: Minimally invasive cytoreductive nephrectomy is feasible and safe in experienced hands with acceptable morbidity and oncological outcomes.

Minimally invasive management of urological fistulas.

PURPOSE OF REVIEW: Urological fistulas are an underestimated problem worldwide and have devastating consequences for patients. Many urological fistulas result from surgical complications and/or inadequate perinatal obstetric healthcare. Surgical correction is the standard treatment. This article reviews minimally invasive surgical approaches to manage urological fistulas with a particular emphasis on the robotic techniques of fistula correction. RECENT FINDINGS: In recent years, many surgeons have explored a minimally invasive approach for the management of urological fistulas. Several studies have demonstrated the feasibility of laparoscopic surgery and the reproducibility of reconstructive surgery techniques. Introduction of the robotic platform has provided significant advantages given the improved dexterity and exceptional vision that it confers. SUMMARY: Fistulas are a concern worldwide. Laparoscopic surgery correction has been developed through the efforts of several authors, and difficulties such as the increased learning curve have been overcome with innovations, including the robotic platform. Although minimally invasive surgery offers numerous advantages, the most successful approach remains the one with the surgeon is most familiar.

Feasibility and continence outcomes of extended prostatic urethral preservation during robot-assisted radical prostatectomy.

BACKGROUND: The prostatic urethra is conventionally resected during robot-assisted radical prostatectomy (RARP). We describe the technical feasibility and urinary continence outcomes of extended prostatic urethral preservation (EPUP) during RARP. METHODS: A single surgeon at a National Comprehensive Cancer Network institute performed 48 consecutive RARP operations using EPUP from March 2014 to March 2016, during which time 177 conventional non-EPUP RARP operations were performed by other surgeons. Prior to this period, the EPUP surgeon had performed 17 non-EPUP RARP operations over 15 months. Total intracorporeal urethral length (IUL) preserved during EPUP was measured intraoperatively. Associations of EPUP and IUL with continence recovery rates and/or times were tested in Fisher's exact and log rank univariate analyses and Cox logistic regression multivariable analyses. RESULTS: Median IUL preserved during EPUP was 4.0 cm (range 2.5-6.0 cm), and urethral dissections typically spanned the prostatic apex to mid-gland or base. Seven-week continence rates were significantly higher with versus without EPUP. EPUP patient rates of using 0 or 0-1 pads per day immediately after catheter removal were 19% and 35%, respectively. These rates increased significantly (53% and 76%, respectively), as did the IUL preserved (median 5.0 cm), among more recent EPUP patients (n = 17), which suggested a learning curve. In multivariable analyses including all patients, an EPUP approach was an independent predictor of faster continence recovery. In multivariable analyses of the EPUP subset, a longer IUL preserved was independently associated with faster continence recovery. No EPUP patient had a urethral fossa positive margin, and apical positive margins were similarly infrequent among EPUP and non-EPUP patients. CONCLUSIONS: EPUP is technically feasible during RARP and associated with faster continence recovery. Future investigation into the generalizability of these findings and the oncologic safety of EPUP is warranted.

Case Report: Double penile fracture.

Penile fracture is an underreported surgical emergency. It usually occurs as a single rupture of the tunica albuginea in one of two corpora cavernosa; a rupture of both masses is an uncommon finding. We report a case of a young male who presented to the emergency department two hours after sustaining penile trauma. Prompt surgical exploration was performed four hours post-injury. He was found to have one fracture on each corpora cavernosa, without urethral injury, which were repaired successfully. The patient had a favorable recovery and was discharged on the third postoperative day without complications. The aim of this report is to highlight the importance of complete degloving of the penile shaft for a meticulous search during surgery to avoid missed injuries. This approach will ensure a successful outcome avoiding physical and psychological disabilities.

One-Year Outcome Comparison of Laparoscopic, Robotic, and Robotic Intrafascial Simple Prostatectomy for Benign Prostatic Hyperplasia.

OBJECTIVE: To compare preoperative, intraoperative, and postoperative variables at 1, 6, and 12 months after laparoscopic simple prostatectomy (LSP), robotic simple prostatectomy (RSP), and intrafascial robotic simple prostatectomy (IF-RSP). PATIENTS AND METHODS: From January 2003 to November 2014, 315 simple prostatectomies were performed using three techniques, LSP, RSP, and IF-RSP; of the patients who underwent these procedures, 236 met the inclusion criteria for this study. RESULTS: No statistically significant difference (SSD) was found in preoperative or perioperative variables. Of the postoperative variables that were analyzed, an SSD (p > 0.01) in prostate-specific antigen levels was found, with levels of 0.07 ± 1.1 ng/mL following IF-RSP, and the detection rate of prostate adenocarcinoma (26%) and high-grade prostatic intraepithelial neoplasia (HG-PIN; 12%) was higher for IF-RSP. We also found that lower International Prostate Symptom Scores (IPSS) were associated with LSP, at 4.8 ± 3.2. Erectile function was reduced in IF-RSP patients in the first 6 months after surgery but was similar in all patient groups at 12 months after surgery; continence and other measured parameters were also similar at 12 months for all three techniques. CONCLUSION: The IF-RSP technique is safe and effective, with results at 1-year follow-up for continence, IPSS, and Sexual Health Inventory for Men scores similar to those for the LSP and RSP techniques. IF-RSP also offers the advantages that it does not require postoperative irrigation, has an increased ability to detect prostate cancer (CA) and HG-PIN, and avoids the risk of future cancer and subsequent reintervention for possible new prostate growth.

Avoiding and managing vascular injury during robotic-assisted radical prostatectomy.

There has been an increase in the number of urologic procedures performed robotically assisted; this is the case for radical prostatectomy. Currently, in the USA, 67% of prostatectomies are performed robotically assisted. With this increase in robotic urologic surgery it is clear that there are more surgeons in their learning curve, where most of the complications occur. Among the complications that can occur are vascular injuries. These can occur in the initial stages of surgery, such as in accessing the abdominal cavity, as well as in the intraoperative or postoperative setting. We present the most common vascular injuries in robot-assisted radical prostatectomy, as well as their management and prevention. We believe that it is of vital importance to be able to recognize these injuries so that they can be prevented.

Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European-American Multi-institutional Analysis.

BACKGROUND: Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique. OBJECTIVE: To report a large multi-institutional series of minimally invasive SP (MISP). DESIGN, SETTING, AND PARTICIPANTS: Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis. INTERVENTION: Laparoscopic or robotic SP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score <8, maximum flow rate >15ml/s, and no perioperative complications. RESULTS AND LIMITATIONS: Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100ml (range: 89-128). Median estimated blood loss was 200ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p=0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p=0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss (p=0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. CONCLUSIONS: This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications. PATIENT SUMMARY: Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.