Daniel Eun

Rectal Injury During Robot-Assisted Radical Prostatectomy: Incidence and Management

PURPOSE Rectal injury during robot-assisted radical prostatectomy is a rare but significant complication. Since the Clavien grading classification of complications does not include intraoperative injury without further sequelae, rectal injury may be underreported in the literature. We present what is to our knowledge the largest retrospective review to date of rectal injury and subsequent management. MATERIALS AND METHODS We reviewed the records of 6,650 patients who underwent robot-assisted radical prostatectomy at a total of 6 institutions. Patient characteristics, perioperative parameters, pathological findings and rectal injury management were tabulated and analyzed for intraoperative predictors of outcome and subsequent management. RESULTS A total of 11 rectal injury cases were identified of the 6,650 robot-assisted radical prostatectomies for a combined 0.17% incidence of rectal injury. Of rectal injuries 72.7% were identified intraoperatively and most did well with primary closure. Delayed recognition injury presented as rectourethral fistula without septic complications and required delayed fistula repair after primary diversion. We found no conclusive association of rectal injury with any patient parameter, intraoperative differences, pathological finding or surgeon experience. Posterior prostate plane dissection, including seminal vesicle dissection, is the crucial stage when rectal injury can occur and be identified. CONCLUSIONS Our review of the records at 6 centers revealed a combined 0.17% incidence of rectal injury. This compares favorably to the incidence in modern open and laparoscopic radical prostatectomy series. No preoperative, intraoperative or pathological differences correlated with injury. Cases in which rectal injury was identified intraoperatively required fewer surgical repeat interventions but ultimately each group had acceptable long-term urinary and bowel function results.

Surgical competency for urethrovesical anastomosis during robot-assisted radical prostatectomy: development and validation of the robotic anastomosis competency evaluation.

OBJECTIVE To develop and validate an assessment tool for the performance of urethrovesical anastomosis (UVA). METHODS A multicenter, prospective, observational study was conducted in 2 phases. Phase 1, development and content validation, used a panel of 5 experienced robotic surgeons to develop a 6-domain scoring system, Robotic Anastomosis Competence Evaluation (RACE), to assess technical skills for performing UVA. Phase 2, construct validation and reliability, used 5 blinded experienced robotic surgeons to rate UVA recordings of expert, advanced beginner, and novice groups. Content validation index was determined to report consensus in phase 1. Phase 2 involved comparison of RACE scores among the 3 groups. Wilcoxon rank-sum tests were used to compare RACE scores. RESULTS Two rounds of Delphi methodology achieved consensus on language and content of RACE. Eight experts, 10 advanced beginners, and 10 novice robotic surgeons participated in the validation study. The overall score for the expert group (27.3) was higher than that of the advanced beginner (19.5; P = .04) and novice groups (13.6; P = .001). The advanced beginner and novice groups differed in overall scores (P = .03). CONCLUSION RACE allows evaluation of surgical competence to perform UVA for robot-assisted radical prostatectomy, when using an inanimate model.

Prevention of iatrogenic ureteral injuries during robotic gynecologic surgery: a review.

Iatrogenic ureteral injuries, more than half of which occur during gynecologic surgery, may have devastating consequences for both patients and physicians. Gynecologists have employed various techniques such as cystoscopy, ureteral stents, and lighted ureteral stents to prevent ureteral injuries. The emergence and increasing prevalence of robotic surgery necessitates that we not only reevaluate the utility of these techniques, but also develop new ones specific for the robotic modality. In the robotic setting, the surgeon lacks tactile feedback and must rely primarily on visual cues. The use of intraureteral indocyanine green and subsequent visualization under near-infrared fluorescence appears to be a promising technique to primarily and secondarily prevent ureteral injuries during robotic gynecologic surgery.

ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY AFTER TURP: A MULTI-INSTITUTIONAL ANALYSIS OF ONCOLOGIC AND QUALITY OF LIFE OUTCOMES

1007 ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY AFTER TURP: A MULTI-INSTITUTIONAL ANALYSIS OF ONCOLOGIC AND QUALITY OF LIFE OUTCOMES Andrew J Bernstein, Daniel Eun, Mark H Katz*, Michael K Eng, Ronald S Boris, Sergey A Shikanov, Arieh L Shalhav, Gregory P Zagaja, James O Peabody, Kevin C Zorn, Mani Menon. Chicago, IL, and Detroit, M

Robot-assisted partial nephrectomy for large renal masses: a multi-institutional series.

To compare peri‐operative outcomes after robot‐assisted partial nephrectomy (RAPN) for cT2a (7 to <10 cm) to cT1 tumours.

Comparison of Perioperative and Functional Outcomes of Robotic Partial Nephrectomy for cT1a versus cT1b Renal Masses

To compare perioperative and functional outcomes of patients with cT1a or cT1b renal masses undergoing robotic partial nephrectomy (RPN) in a large multi‐institutional study

Multi-institution analysis of racial disparity among African- American men eligible for prostate cancer active surveillance

There is a significant controversy on whether race should be a factor in considering active surveillance for low-risk prostate cancer. To address this question, we analyzed a multi-institution database to assess racial disparity between African-American and White-American men with low risk prostate cancer who were eligible for active surveillance but underwent radical prostatectomy. A retrospective analysis of prospectively collected clinical, pathologic and oncologic outcomes of men with low-risk prostate cancer from seven tertiary care institutions that underwent radical prostatectomy from 2003–2014 were used to assess potential racial disparity. Of the 333 (14.8%) African-American and 1923 (85.2%) White-American men meeting active surveillance criteria, African-American men were found to be slightly younger (57.5 vs 58.5 years old; p = 0.01) and have higher BMI (29.3 v 27.9; p < 0.01), pre-op PSA (5.2 v 4.7; p < 0.01), and maximum percentage cancer on biopsy (15.1% v 13.6%; p < 0.01) compared to White-American men. Univariate and multivariate analysis demonstrated similar rates of upgrading, upstaging, positive surgical margin, and biochemical recurrence between races. These results suggest that single institution studies recommending more stringent AS enrollment criteria for AA men with a low-risk prostate cancer may not capture the complete oncologic landscape due to institutional variability in cancer outcomes. Since all seven institutions demonstrated no significant racial disparity, current active surveillance eligibility should not be modified based upon race until a prospective study has been completed.

Use of Age and Medical Comorbidity to Assess Long Term Other-Cause Mortality Risk in a Cohort of Men Undergoing Prostate Biopsy at an Academic Medical Center.

OBJECTIVE To assess life expectancy and biopsy outcomes in men undergoing prostate biopsy at an academic medical center. METHODS We analyzed men who underwent prostate biopsy at our medical center between July 2012 and June 2014. Long-term other-cause mortality risk was determined using survival tables. Indications for biopsy and biopsy outcomes were assessed, and compared among men with varying mortality risks. RESULTS A total of 417 men underwent prostate biopsy, in whom 14-year other-cause mortality risk ranged from 9% to 74%. One hundred ninety-three men (46.3%) were considered low-mortality risk (<40% risk of 14-year mortality), 131 (31.4%) intermediate risk (41%-55% 14-year mortality), and 93 (22.3%) high risk (>55% 14-year mortality). Of the 417 patients who underwent biopsy, 149 (35.7%) were found to have prostate cancer. There was no significant difference in the rate of positive biopsies (P = .72), distribution of Gleason scores (P = .60), or percentage of positive biopsy cores (P = .74) between mortality risk groups. However, by UCSF Cancer of the Prostate Risk Assessment score, there was significant trend toward higher-risk prostate cancer in men with intermediate and high-mortality risk (P = .04). CONCLUSION In this analysis, a large number of men with limited life expectancies underwent prostate biopsy. The majority of these men had negative biopsies or low-risk cancers, suggesting that they were unlikely to benefit from biopsy. To avoid potentially unnecessary prostate biopsies, the practitioner must give serious consideration to a patients age and medical comorbidities before making a recommendation as to whether biopsy should be performed.

Robotic Appendiceal Interposition With Right Lower Pole Calycostomy, Downward Nephropexy, and Psoas Hitch for the Management of an Iatrogenic Near-complete Ureteral Avulsion

Although iatrogenic ureteral injuries are rare, they have potentially devastating consequences for both patients and physicians, and their management remains challenging. We report a case of a 51-year-old morbidly obese (body mass index = 63) woman who suffered an iatrogenic 15-cm right ureteral avulsion during hysteroscopic biopsy. Preoperative antegrade and retrograde pyelograms demonstrated no true renal pelvis and a 3-cm blind-ending distal ureteral stump. The patient underwent a right robotic downward nephropexy, psoas hitch, lower pole calycostomy, and 11-cm appendiceal interposition. At 6 months postoperatively, renal scan demonstrated stable right renal function with no evidence of obstruction.

PD66-04 SOME MINUTES COUNT MORE THAN OTHERS: VARIATION IN WARM ISCHEMIA TIME ≤ 25 MINUTES HAS NO EFFECT ON KIDNEY FUNCTION IN PATIENTS WITHOUT IMPAIRED RENAL FUNCTION

cohort, 4 patients (3%) experienced disease recurrence. A total of 6 patients (4%) died during follow up and 4 patients (3%) were felt to have died of disease. In chromophobe patients who developed disease recurrence, tumors were predominantly larger (mean 12.3cm) with sarcomatoid differentiation in 50%. CONCLUSIONS: Variant tumors with oncocytic features behave more like oncocytoma than renal cell carcinoma. “Atypical features”, when present, are permissible as long as the gross appearance remains compatible with oncocytoma. These tumors require little to no post-operative surveillance as opposed to chromophobe RCC, where follow up is warranted. Whether surgery can be obviated altogether when these tumors are diagnosed on preoperative renal mass biopsy requires further evaluation.