E. Checcucci

Robot-assisted Surgery for Benign Ureteral Strictures: Experience and Outcomes from Four Tertiary Care Institutions

BACKGROUND Minimally invasive treatment of benign ureteral strictures is still challenging because of its technical complexity. In this context, robot-assisted surgery may overcome the limits of the laparoscopic approach. OBJECTIVE To evaluate outcomes for robotic ureteral repair in a multi-institutional cohort of patients treated for ureteropelvic junction obstruction and ureteral stricture (US) at four tertiary referral centres. DESIGN, SETTING, AND PARTICIPANTS This retrospective study reports data for 183 patients treated with standard robot-assisted pyeloplasty (PYP) and robotic uretero-ureterostomy (UUY) at four high-volume centres from January 2006 to September 2014. SURGICAL PROCEDURE Robotic PYP and robot-assisted UUY were performed according to previously reported surgical techniques. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS No robot-assisted UUY cases required surgical conversion, while 2.8% of PYP cases were not completed robotically. The median operative time was 120 and 150min for robot-assisted PYP and robot-assisted UUY, respectively. No intraoperative complications were reported. The overall complication rate for all procedures was 11% (n=20) and complications were mostly of low grade. The high-grade complication rate was 2.2% (n=4). At median follow-up of 24 mo, the overall success rate was >90% for both procedures. The study limitations include its retrospective nature and the heterogeneity of the study population. CONCLUSIONS Robotic surgery for benign US is safe and effective, with limited risk of high-grade complications and good intermediate-term results. PATIENT SUMMARY In this study we review the use of robotic surgery at four different tertiary care centres in the treatment of patients affected by benign ureteral strictures. Our results demonstrate that robotic surgery is a safe alternative to the standard open approach in the treatment of ureteral strictures.

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).

Five-year Outcomes for a Prospective Randomised Controlled Trial Comparing Laparoscopic and Robot-assisted Radical Prostatectomy

BACKGROUND The literature is lacking randomised controlled trials comparing robot-assisted (RARP) and laparoscopic (LRP) radical prostatectomy, especially for follow-up >1 yr. OBJECTIVE To report 5-yr outcomes for our previously published prospective randomised study comparing RARP and LRP. DESIGN, SETTING, AND PARTICIPANTS From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned to RARP or LRP. INTERVENTION A single surgeon performed all interventions using the same transperitoneal anterograde technique. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Continence, potency, and serum prostate-specific antigen were assessed postoperatively at 1, 3, 6, and 12 mo, and then every 6 mo until 60 mo. At the end of the follow-up period, patients were administered questions 1 and 46 of the Expanded Prostate Cancer Index Composite questionnaire to assess their satisfaction with the intervention and general health status. A generalised estimating equations model was used to compare time series data for functional results, and Kaplan-Meier and Cox models were used to analyse oncologic outcomes. RESULTS AND LIMITATIONS The probability of achieving continence (odds ratio [OR] 2.47, p<0.021) and potency (OR 2.35, p<0.028) over time was more than doubled for the RARP compared to the LRP group. There was no difference between the two approaches in terms of patient survival. Pathologic Gleason score, positive surgical margins, and pT stage were associated with significantly higher biochemical recurrence in Cox multivariate models. Patient satisfaction with the intervention and their general health status was significantly higher in the RARP group. CONCLUSIONS Throughout the 5-yr follow-up, RARP yielded better functional results compared to LRP, without compromising oncologic outcomes. PATIENT SUMMARY In this report we looked at 5-yr outcomes for a study comparing robot-assisted radical prostatectomy (RARP) and laparascopic radical prostatectomy for the treatment of prostate cancer. We found that continence and potency are better among patients treated with RARP, while oncologic results are comparable.

Hyperaccuracy Three-dimensional Reconstruction Is Able to Maximize the Efficacy of Selective Clamping During Robot-assisted Partial Nephrectomy for Complex Renal Masses

BACKGROUND Available technologies could avoid global ischemia for the removal of a renal tumor. OBJECTIVE To present hyperaccuracy three-dimensional (HA3D) reconstruction during robot-assisted partial nephrectomy (RAPN) and compare its efficacy in sponsoring successful selective clamping of renal arterial branches during RAPN. DESIGN, SETTING, AND PARTICIPANTS Patients undergoing RAPN (January 2016-July 2017) for renal mass PADUA score ≥10 who underwent abdominal computed tomography scan with angiography. Since February 2017 HA3D reconstruction was performed. SURGICAL PROCEDURE HA3D reconstruction-aided RAPN and standard RAPN with selective clamping. MEASUREMENTS Intraoperative variables focusing on the renal arterial pedicle management and success rate of its planned management. RESULTS AND LIMITATIONS Thirty-one patients in group no HA3D and 21 in group HA3D. The median (standard deviation) tumor size was 50.9 and 50.8mm (p=0.97), and median PADUA scores 10.5 and 11 (p=0.85) for groups no HA3D and HA3D, respectively. In group no HA3D, a significantly higher number of patients underwent global ischemia (80% vs 24%, p<0.01). Of note, in 90% of the group HA3D cases, intraoperative management of the renal pedicle was performed as preoperatively planned; in 39% of the group no HA3D cases, management of the renal arterial pedicle was varied intraoperatively (p=0.04). We disclose the limited sample size and the experimental technique. CONCLUSIONS Preoperative simulation of selective ischemia was feasible and effective with HA3D reconstruction. In all the RAPN cases performed, selective clamping was successful, avoiding ischemia of the healthy renal remnant. A strict collaboration between urologists and bioengineers is mandatory to improve the technology. PATIENT SUMMARY In this report, we found that an accurate three-dimensional reconstruction of the kidney before conservative surgery for renal cancer seems to help in avoiding the global ischemia of the kidney. Further studies are needed to conclude if avoiding a percentage of ischemia to the kidney is clinically relevant.

Laparoscopic Nephron-Sparing Calycectomy for Treating Fraley's Syndrome

Background/Aims/Objectives: Various nephron-sparing approaches were described as part of surgical management for Fraley’s syndrome, a rare anatomic variant of the renal vascular anatomy that compresses the upper pole infundibulum resulting in an upper calyceal obstruction and dilatation, with symptoms of flank pain and hematuria. To date, descriptions of minimally invasive correction techniques are anecdotal. Methods: A retroperitoneal pure laparoscopic approach using the nephron-sparing technique was chosen in the presented case. Results: In this report, we demonstrated that if laparoscopic calycectomy is performed without clamping of renal branches, parenchymal ischemia can be completely avoided. Additionally, the preservation of renal tissue surrounding the calyx enables the preservation of the intrasinusal segmental arteries flow, thereby avoiding their accidental closure by hemostatic sutures. Conclusions: In conclusion, Laparoscopic Nephron-Sparing Calycectomy is a safe and effective surgical procedure for the treatment of Fraley’s syndrome. Consistent laparoscopic experience is required before embarking on this kind of surgery.

Use of chitosan membranes after nerve-sparing radical prostatectomy improves early recovery of sexual potency: results of a comparative study

To evaluate the 1‐year efficacy of chitosan membrane (ChiMe) application on the neurovascular bundles (NVBs) after nerve‐sparing (NS) robot‐assisted radical prostatectomy (RARP) in potency recovery rate. To compare the results with those of a contemporary cohort of patients who did not benefit from chitosan use.

Augmented-reality robot-assisted radical prostatectomy using hyper-accuracy three-dimensional reconstruction (HA3D™) technology: a radiological and pathological study

To assess the use of hyper‐accuracy three‐dimensional (HA3D™; MEDICS, Moncalieri, Turin, Italy) reconstruction based on multiparametric magnetic resonance imaging (mpMRI) and superimposed imaging during augmented‐reality robot‐assisted radical prostatectomy (AR‐RARP).

PD18-06 5 YEARS FOLLOW-UP OF A PROSPECTIVE RANDOMISED CONTROLLED TRIAL COMPARING LAPAROSCOPIC VERSUS ROBOT-ASSISTED RADICAL PROSTATECTOMY: ONCOLOGICAL AND FUNCTIONAL OUTCOMES

evaluated the association of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) with sociodemographic characteristics, family history of PC, global health score/quality of life (EORTC quality of life questionnaire-C30 subscale), depression/anxiety (Patient Health Questionnaire 4), latest PSA-level >1⁄4 0.2 ng/ml, time since RP and current therapy using hierarchical multiple regression analysis. RESULTS: Mean age at survey was 75.2 years with a median follow-up of 11.5 years. The final regression model showed younger age, lower global health status/quality of life, higher depression/anxiety scores, higher latest PSA-level and shorter time since RP predicting a higher level of PSAand PC Anxiety, respectively. Familial PC predicted only for PSA-Anxiety (all p < 0.05). The final regression model explained 12% of the variance for PSA-Anxiety and 24% for PCAnxiety. CONCLUSIONS: PC-specific anxiety is still relevant even many years after surgery. Besides depression and anxiety, younger age, shorter time since RP and a rising PSA-level play an important role during follow-up. Survivors who fulfill these characteristics are at higher risk to develop PC-specific anxiety which have need to be kept in mind by the treating physician regarding to a successful follow-up.