Achilles Ploumidis

Biochemical recurrence after robot-assisted radical prostatectomy in a European single-centre cohort with a minimum follow-up time of 5 years.

BACKGROUND Robot-assisted radical prostatectomy (RARP) is an increasingly commonly used surgical treatment option for prostate cancer (PCa); however, its longer-term oncologic results remain uncertain. OBJECTIVE To report biochemical recurrence-free survival (BRFS) outcomes for men who underwent RARP ≥5 yr ago at a single European centre. DESIGN, SETTING, AND PARTICIPANTS A total of 944 patients underwent RARP as monotherapy for PCa from January 2002 to December 2006 at Karolinska University Hospital, Stockholm, Sweden. Standard clinicopathologic variables were recorded and entered into a secure, ethics-approved database made up of those men with registered domiciles in Stockholm. The median follow-up time was 6.3 yr (interquartile range: 5.6-7.2). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The outcome of this study was biochemical recurrence (BCR), defined as a confirmed prostate-specific antigen (PSA) of ≥0.2 ng/ml. Kaplan-Meier survival plots with log-rank tests, as well as Cox univariable and multivariable regression analyses, were used to determine BRFS estimates and determine predictors of PSA relapse, respectively. RESULTS AND LIMITATIONS The BRFS for the entire cohort at median follow-up was 84.8% (95% confidence interval [CI], 82.2-87.1); estimates at 5, 7, and 9 yr were 87.1% (95% CI, 84.8-89.2), 84.5% (95% CI, 81.8-86.8), and 82.6% (95% CI, 79.0-85.6), respectively. Nine and 19 patients died of PCa and other causes, respectively, giving end-of-follow-up Kaplan-Meier survival estimates of 98.0% (95% CI, 95.5-99.1) and 94.1% (95% CI, 90.4-96.4), respectively. Preoperative PSA >10, postoperative Gleason sum ≥4 + 3, pathologic T3 disease, positive surgical margin status, and lower surgeon volume were associated with increased risk of BCR on multivariable analysis. This study is limited by a lack of nodal status and tumour volume, which may have confounded our findings. CONCLUSIONS This case series from a single, high-volume, European centre demonstrates that RARP has satisfactory medium-term BRFS. Further follow-up is necessary to determine how this finding will translate into cancer-specific and overall survival outcomes.

The impact of length and location of positive margins in predicting biochemical recurrence after robot-assisted radical prostatectomy with a minimum follow-up of 5 years

To evaluate the role of positive surgical margin (PSM) size/focality and location in relation to risk of biochemical recurrence (BCR) after robot‐assisted radical prostatectomy (RARP).

Robot-assisted Sacrocolpopexy for Pelvic Organ Prolapse: Surgical Technique and Outcomes at a Single High-volume Institution

BACKGROUND Pelvic organ prolapse (POP) represents a common female pelvic floor disorder that has a serious impact on quality of life. Several types of procedures with different surgical approaches have been described to correct these defects, but the optimal management is still debated. OBJECTIVE To describe our surgical technique of robot-assisted sacrocolpopexy (RASC) for POP and to assess its safety and long-term outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of the medical records of 95 consecutive patients who underwent RASC for POP at our centre from April 2006 to December 2011 was performed. SURGICAL PROCEDURE RASC with use of polypropylene meshes was performed in all cases using a standardised technique with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in a four-arm configuration. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Clinical data were collected in a dedicated database. Intraoperative variables, postoperative complications, and outcomes of RASC were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS Median operative time was 101 min. No conversion to open surgery was needed. One vaginal and two bladder injuries occurred and were repaired intraoperatively. Only one Clavien grade 3 postoperative complication was observed (bowel obstruction treated laparoscopically). At a median follow-up of 34 mo, persistent POP was observed in four cases (4.2%). One mesh erosion occurred and required robot-assisted removal of the mesh. Ten (10.5%) patients complained de novo urgency after RASC, which resolved in the first few weeks after surgery. No significant de novo bowel or sexual symptoms were reported. CONCLUSIONS Our technique of RASC for correction of POP is safe and effective, with limited risk of complications and good long-term results in the treatment of all types of POP. The robotic surgical system facilitates precise and accurate placement of the meshes with short operative time, thereby favouring wider diffusion of minimally invasive treatment of POP. PATIENT SUMMARY We studied the treatment of patients with vaginal prolapse by using a robot-assisted surgical technique to fix the vaginal wall with a synthetic mesh. This technique was found to be safe and effective, with limited risk of complications and good long-term results.

The Infancy of Robotic Laparoendoscopic Single-Site Renal Surgery: Waiting for Needed Technological Improvements

Traditional open surgery has provided us with an impressive heritage of proven oncologic and functional results, establishing principles that will be hard to surpass and a standard to which any other technique is compared. Nonetheless, large incisions with extended dissection accompanied by prolonged surgical stress are some of the drawbacks of conventional surgery, with a direct relationship to the patient’s convalescence. In an effort to overcome these disadvantages, pioneering surgeons in the early 1990s introduced laparoscopy in urology [1]. Although many agreed about its feasibility, few really believed it could replace conventional open surgery. Over time, laparoscopy evolved and expanded from nephrectomy to other fields of urology, thanks to the experience of leading surgical teams and technical innovations in instrumentation. Today, laparoscopy is well established but with a significant learning curve. Recently, with the advent of the robotic platform, even open surgeons with minimal training in laparoscopy can add a laparoscopic environment to their armamentarium and offer their patients a minimally invasive procedure [2]. With widespread acceptance of minimal access operations among patients and surgeons in the urologic community, surgical evolution has gone one step further by reducing access to a single port. Although single-access surgery is still in its infancy, in a multi-institutional study, >1000 laparoendoscopic single-site surgery (LESS) procedures were reported [3]. In an effort to achieve intraabdominal triangulation, crossing of the instruments is needed, forcing the surgeon to use counterintuitive movements. Flexible and prebent laparoscopic instruments accompanied by flexible optics only partially restore the triangulation and alleviate the ergonomic challenge posed

Spontaneous Retroperitoneal Hemorrhage (Wunderlich Syndrome) due to Large Upper Pole Renal Angiomyolipoma: Does Robotic-Assisted Laparoscopic Partial Nephrectomy Have a Role in Primary Treatment?

Spontaneous rapture with consequent retroperitoneal hemorrhage (Wunderlichs syndrome) is the complication mostly feared from large renal angiomyolipomas (RAMLs). In hemodynamic stable patients, minimal invasive therapies have superseded open surgery as the mainstay of treatment, with contemporary cases mostly treated by selective arterial embolization. Robotic-assisted laparoscopic partial nephrectomy (RALPN) is an established minimal access treatment that has been used in the past for benign and malignant lesions of the kidney in the elective setting, but rarely in urgent situations as primary treatment. We present a case of a ruptured RAML in a young female treated effectively by RALPN.

Isolated Male Epispadias: Anatomic Functional Restoration Is the Primary Goal.

Background. Isolated male epispadias (IME) is a rare congenital penile malformation, as often part of bladder-exstrophy-epispadias complex (BEEC). In its isolated presentation, it consists in a defect of the dorsal aspect of the penis, leaving the urethral plate open. Occurrence of urinary incontinence is related to the degree of dorsal displacement of the meatus and the underlying underdevelopment of the urethral sphincter. The technique for primary IME reconstruction, based on anatomic restoration of the urethra and bladder neck, is here illustrated. Patients and Methods. A retrospective database was created with patients who underwent primary IME repair between June 1998 and February 2014. Intraoperative variables, postoperative complications, and outcomes were assessed. A descriptive statistical analysis was performed. Results and Limitations. Eight patients underwent primary repair, with penopubic epispadias (PPE) in 3, penile epispadias (PE) in 2, and glandular epispadias (GE) in 3. Median age at surgery was 13.0 months [7–47]; median follow-up was 52 months [9–120]. Complications requiring further surgery were reported in two patients, while further esthetic surgeries were required in 4 patients. Conclusion. Anatomical restoration in primary IME is safe and effective, with acceptable results given the initial pathology.

Metastasis to Sartorius Muscle from a Muscle Invasive Bladder Cancer

Bladder cancer constitutes the ninth most common cancer worldwide and approximately only 30% of cases are muscle invasive at initial diagnosis. Regional lymph nodes, bones, lung, and liver are the most common metastases from bladder cancer and generally from genitourinary malignancies. Muscles constitute a rare site of metastases from distant primary lesions even though they represent 50% of total body mass and receive a large blood flow. Skeletal muscles from urothelial carcinoma are very rare and up to date only few cases have been reported in the literature. We present a rare case of 51-year-old patient with metastases to sartorius muscle 8 months after the radical cystectomy performed for a muscle invasive bladder cancer.

Robot-assisted excision of a pararectal gastrointestinal stromal tumor in a patient with previous ileal neobladder.

Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal tumors of the gastrointestinal tract with surgical resection remaining the cornerstone of therapy. Pararectal lesions are considered to be technically difficult and pose in some cases a challenge. We report, to the best of our knowledge, the first robotic-assisted pararectal GIST excision. A 43-year-old man was referred to our center with pararectal GIST recurrence, despite treatment with targeted therapy. Eleven years ago, he underwent extensive abdominal surgery including cystoprostatectomy with ileal neobladder diversion due to GIST resection in the rectoprostatic space. Robot-assisted surgical resection was successfully performed without the need for temporary colostomy. The postoperative course of the patient was uneventful, and the pathology report confirmed a GIST recurrence with negative surgical margins and pelvic lymph nodes free of any tumor. Robotic-assisted pelvic surgery can be extended to incorporate excision of pararectal GISTs, as a safe, less invasive surgical alternative with promising oncological results and minimal injury to adjacent structures.

Evolution and Uptake of the Endoscopic Stone Treatment Step 1 (EST-s1) Protocol: Establishment, Validation, and Assessment in a Collaboration by the European School of Urology and the Uro-Technology and Urolithiasis Sections

Endourology training has evolved over the last two decades, with more emphasis now being placed on simulation-based training. While the EBLUS training curriculum and examination have been well established [1], there was a lack of standardised training for endourology. The European School of Urology (ESU), together with the European Association of Urology (EAU) sections on uro-technology and urolithiasis, started development of the Endoscopic Stone Treatment step-1 (EST-s1) simulation protocol in 2014. This was produced in accordance with the EAU guidelines by following the full life-cycle curriculum development template. The outcomes and metrics were defined via a cognitive task analysis by the EAU Young Academic Urology group and the simulator requirements were then tested. The final task list consisted of four exercises that replicated the basic skills required for endoscopic stone treatment: (1) flexible cystoscopy; (2) rigid cystoscopy and placement of a safety guidewire; (3) semi-rigid ureteroscopy and placement of an access sheath; and (4) flexible ureterorenoscopy. The curriculum development process took 2 yr of consensus meetings and expert consultation; this led to addition of content validity evidence to the protocol [2]. Face and construct validity data were collected during the annual EUREP course in 2016 and will be reported in an upcoming publication. This validation study involved 124 participants using low-fidelity simulators. The rules for the exercises and the expected goals were strictly derived from the development process and were summarised in a tutor instruction sheet. Video explanation of the tasks was available on the

PD30-09 WHICH FLEXIBLE URETEROSCOPES (DIGITAL VS OPTICAL) CAN EASILY REACH THE DIFFICULT LOWER POLE CALYCES AND HAVE BETTER END-TIP DEFLECTION?

INTRODUCTION AND OBJECTIVES: All modern flexible ureteroscopes have a deflection of at least 270 , but approaching a difficult lower pole acute angled calyx can still be very difficult. The aim of our study was to find which ureteroscopes are better when dealing with a sharp angled calyx and to compare the deflection of the last few centimetres (cm) of the ureteroscope tip. METHODS: Using a training model for flexible ureteroscopy (KBox , Porges-Coloplast), we identified an acute angle calyx and we tried to access it with 9 different ureteroscopes (BOA vision and COBRA vision, Richard Wolf ; FLEX X2 and FLEX Xc, Karl Storz ; LithoVue, Boston Scientific ; URF-P5, URF-P6, URF-V and URF-V2, Olympus ). Passing the scope through a 10/12 Fr ureteral access sheath respectively (using ReTrace, Coloplast sheath) (except 12/14 Fr sheath for COBRA vision), with the tip out at 1 cm, 2 cm, 3 cm and 4 cm, we measured the maximum tip deflection for every ureteroscope. RESULTS: All optical ureteroscopes (URF-P5, FLEX X2) except the URF-P6 were able to access the sharp angled calyx. Except FLEX Xc, none of the digital ureteroscopes reached the difficult calyx. All optical ureteroscopes had better end-tip deflection compared to the digital scopes with the exception of FLEX Xc, which was as deflectable as the optical ureteroscopes. CONCLUSIONS: Digital ureteroscopes tend to be more rigid and the last centimeters of their tip seems to be less flexible, possibly due to the size of the camera capsule. When approaching a difficult, acute angled lower pole calyx, it might be better to use a fibre-optic ureteroscope. Source of Funding: none