D. Amparore

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.

Margins, ischaemia and complications rate after laparoscopic partial nephrectomy: impact of learning curve and tumour anatomical characteristics.

To present our laparoscopic partial nephrectomy (LPN) results according to the margin, ischaemia and complications (MIC) system recently proposed for the standardized reporting of partial nephrectomy (PN) outcomes. To assess the role of learning curve and tumour anatomical characteristics on the outcomes by using MIC system.

Evaluation of functional outcomes after laparoscopic partial nephrectomy using renal scintigraphy: clamped vs clampless technique.

To examine differences in postoperative renal functional outcomes when comparing clampless with conventional laparoscopic partial nephrectomy (LPN) by using renal scintigraphy, and to identify the predictors of poorer postoperative renal functional outcomes after clampless LPN.

Perioperative and renal functional outcomes of elective robot-assisted partial nephrectomy (RAPN) for renal tumours with high surgical complexity.

To evaluate the perioperative, postoperative and functional outcomes of robot‐assisted partial nephrectomy (RAPN) for renal tumours with high surgical complexity at a large volume centre.

Treatment outcomes of partial nephrectomy for T1b tumours.

Purpose of review Nephron-sparing surgery is the standard of care for the treatment of localized renal tumours and is increasingly performed for larger and more challenging lesions. Aim of this review is to analyse the outcomes of partial nephrectomy for the treatment of T1b renal tumours greater than 4 cm in size. Recent findings No randomized trial has compared the outcomes of partial nephrectomy compared to radical nephrectomy for T1b renal tumours. However, several single, multi-institutional and population-based studies consistently showed similar cancer-specific survival rates for open partial nephrectomy (OPN) and radical nephrectomy for tumours greater than 4 cm in size. A decreased loss in renal function was observed with partial nephrectomy compared to radical nephrectomy for T1b tumours. Laparoscopic partial nephrectomy (LPN) for tumours greater than 4 cm in size was shown to obtain similar short-to-intermediate-term oncological outcomes of laparoscopic radical nephrectomy and OPN in experienced centres, but is associated with longer warm ischaemia time and higher complication rates. The initial series of robot-assisted partial nephrectomy show similar perioperative results and decreased warm ischaemia time compared to LPN, whereas the oncological outcomes are still immature. Summary Partial nephrectomy for T1b renal tumours achieves comparable oncological outcomes and better preservation of renal function compared to radical nephrectomy and should be performed whenever technically possible. OPN remains at present the gold standard technique. LPN represents an alternative to OPN in centres with advanced laparoscopic expertise. Robot-assisted partial nephrectomy has the potential to overcome the drawbacks of pure laparoscopic surgery, but larger series and longer follow-up are needed to further define its role in the management of T1b tumours.

Mini-retroperitoneoscopic clampless partial nephrectomy for "low-complexity" renal tumours (PADUA score ≤8)

An alternative to conventional laparoscopy when looking for virtually scarless surgery is mini-laparoscopy, a reproducible technique that preserves the triangulation concept. A drawback of this approach is the poor image quality provided by mini-scopes. The introduction of the SPIEs technology, a novel endoscopic camera allowing for better visualisation of anatomic details even with 3-mm optics, has boosted the use of a mini-laparoscopic approach in our centre for laparoscopic partial nephrectomy (LPN) to treat low-complexity renal masses. Allowing for inclusion criteria, 10 consecutive patients who satisfied inclusion criteria were enrolled in our prospective study undergoing clampless mini-retroperitoneoscopic LPN performed by a single surgeon with laparoscopic expertise. Preliminary data show that the approach seems to be safe and effective, with comparable outcomes to conventional LPN. Larger sample size and comparative studies are needed to confirm these findings. The evaluation of cosmetic results will be the focus of further studies.

Temporary implantable nitinol device (TIND): a novel, minimally invasive treatment for relief of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH): feasibility, safety and functional results at 1 year of follow‐up

To report the first clinical experience with a temporary implantable nitinol device (TIND; Medi‐Tate®) for the treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).

Development and validation of 3D printed virtual models for robot-assisted radical prostatectomy and partial nephrectomy: urologists’ and patients’ perception

PurposeTo test the face and content validity of 3D virtual-rendered printed models used before robot-assisted prostate cancer and nephron-sparing surgery.MethodsPatients who underwent live surgery during an international urological meeting organized in January 2017 were enrolled. Those with organ-confined prostate cancer underwent robot-assisted radical prostatectomy. Patients with a single renal tumor underwent minimally invasive nephron-sparing surgery. High-resolution (HR) imaging was obtained for all patients. Those with kidney tumors received contrast-enhanced CT scan with angiography; those with prostate cancer underwent mp-MRI. Images in DICOM format were processed by dedicated software. The first step was the rendering of a 3D virtual model. The models were then printed. They were presented during the live surgery of the urological meeting. All the participants and the operated patients were asked to fill a questionnaire about their opinion expressed in Likert scale (1–10) about the use and application of the 3D printed models.Results18 patients were enrolled, including 8 undergoing robot-assisted radical prostatectomy and 10 undergoing minimally invasive partial nephrectomy. For each patient, a virtual 3D printed model was created. The attendants rated the utility of printed models in surgical planning, anatomical representation and the role of technology in surgical training as 8/10, 10/10 and 9/10, respectively. All patients reported favorable feedbacks (from 9 to 10/10) about the use of the technology during the case discussion with the surgeon.ConclusionsIn our experience, 3D printing technology has been perceived as a useful tool for the purpose of surgical planning, physician education/training and patient counseling. Further researches are expected to increase the level of evidence.

Multiparametric Magnetic Resonance/Ultrasound Fusion Prostate Biopsy: Number and Spatial Distribution of Cores for Better Index Tumor Detection and Characterization

Purpose: We evaluated the minimum core number for better index tumor detection to determine the best core site as well as biopsy Gleason score heterogeneity in the same index lesion. The aim was to optimize the highest Gleason score detection. Materials and Methods: A total of 327 patients with negative digital rectal examination underwent magnetic resonance imaging/transrectal ultrasound fusion targeted biopsy for elevated/rising prostate specific antigen and/or 1 or more detectable lesions on multiparametric magnetic resonance imaging after a previous negative standard biopsy. Depending on the diameter of each index lesion (8 or less, or greater than 8 mm) 4 or 6 cores, respectively, were taken according to a well determined sequence. Results: Of the patients 166 (50.7%) had prostate cancer, including 79 (47.6%) with an 8 mm or less index lesion and 87 (52.4%) with a greater than 8 mm index lesion. Of patients with an index tumor 8 mm or less 7 (8.9%) had 1, 31 (39.2%) had 2, 27 (34.2%) had 3 and 14 (17.7%) had 4 positive cores. Similarly, of patients with a lesion greater than 8 mm 8 (9.2%) had 1, 30 (34.5%) had 2, 13 (14.9%) had 3, 14 (16.1%) had 4, 12 (13.8%) had 5 and 10 (11.5%) had 6 positive cores. The major prevalence of positive cores was observed in the center of the target. Gleason score heterogeneity was found in 12.6% of those with an 8 mm or less target vs 26.4% with a target greater than 8 mm. In the center of the target there was a slight prevalence of Gleason pattern 4 or greater, or a lesser pattern. Conclusions: Approaching magnetic resonance imaging/transrectal ultrasound fusion targeted biopsy with a single core might be inadequate. Rather, taking 2 cores in the center of the index lesion may provide more accurate cancer detection and optimize the chances of finding the highest Gleason pattern.

3-Year follow-up of temporary implantable nitinol device implantation for the treatment of benign prostatic obstruction

To report 3‐year follow‐up results of the first implantations with a temporary implantable nitinol device (TIND®; Medi‐Tate Ltd., Or Akiva, Israel) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).