Gabriele Tuderti

Robotic Intracorporeal Padua Ileal Bladder: Surgical Technique, Perioperative, Oncologic and Functional Outcomes

BACKGROUND Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder reconstruction is a challenging procedure. The need for surgical skills and the long operative times have led to concern about its reproducibility. OBJECTIVE To illustrate our technique for RARC and totally intracorporeal orthotopic Padua ileal bladder. DESIGN, SETTING, AND PARTICIPANTS From August 2012 to February 2014, 45 patients underwent this technique at a single tertiary referral centre. SURGICAL PROCEDURE RARC, extended pelvic lymph node dissection, and intracorporeal partly stapled neobladder. Surgical steps are demonstrated in the accompanying video. MEASUREMENTS Demographics, clinical, and pathological data were collected. Perioperative, 2-yr oncologic and 2-yr functional outcomes were reported. RESULTS AND LIMITATIONS Intraoperative transfusion or conversion to open surgery was not necessary in any case and intracorporeal neobladder was successfully performed in all 45 patients. Median operative time was 305min (interquartile range [IQR]: 282-345). Median estimated blood loss was 210ml (IQR: 50-250). Median hospital stay was 9 d (IQR: 7-12). The overall incidence of perioperative, 30-d and 180-d complications were 44.4%, 57.8%, and 77.8%, respectively, while severe complications occurred in17.8%, 17.8%, and 35.5%, respectively. Two-yr daytime and night-time continence rates were 73.3% and 55.5%, respectively. Two-yr disease free survival, cancer specific survival, and overall survival rates were 72.5%, 82.3%, and 82.4%, respectively. The small sample size and high caseload of the centre might affect the reproducibility of these results. CONCLUSIONS Our experience supports the feasibility of totally intracorporeal neobladder following RARC. Operative times and perioperative complication rates are likely to be reduced with increasing experience. PATIENT SUMMARY We report the outcomes of our first 45 consecutive patients who underwent robot-assisted radical cystectomy with intracorporeal neobladders. Perioperative, oncologic, and functional outcomes support this technique as a feasible and safe surgical option in tertiary referral centres.

Purely off‐clamp robotic partial nephrectomy: Preliminary 3‐year oncological and functional outcomes

To describe our surgical technique and to report perioperative, 3‐year oncological and functional outcomes of a single‐center series of purely off‐clamp robotic partial nephrectomy.

V6-07 INTRACORPOREAL PARTLY STAPLED PADUA ILEAL BLADDER USING ROBOTIC STAPLERS: SURGICAL TECHNIQUE, PERIOPERATIVE AND EARLY FUNCTIONAL OUTCOMES OF A PROSPECTIVE SINGLE CENTER SERIES

INTRODUCTION AND OBJECTIVES: Robot assisted radical cystectomy (RARC) with totally intracorporeal orthotopic neobladders is a challenging surgical procedure. The potentially increased risk of neobladders stone formation consequent to the use of staplers to create the neobladders is still a matter of debate. Robotic staplers have been recently made commercially available. In this prospective study (www. clinicaltrials.gov NCT02665156) we assessed the feasibility, safety and time efficiency of RARC with intracorporeal partly stapled “Padua Ileal Bladder” using robotic staplers. METHODS: Twenty-two consecutive patients with muscle invasive or high grade recurrent urothelial carcinoma of the bladder were treated between March 2016 and October 2016. Baseline, perioperative and follow-up data were prospectively collected and maintained into an IRB approved database. Key steps of surgery include: selection of 45 centimeters of ileum and division of the distal and proximal part of the ileum using robotic staplers; detubularization of the ileal loop; creation of the neo-bladder neck with one stapler load; double folding of the proximal ileal loop using two-three stapler loads; hand-sewing of the posterior neobladders wall with barbed suture; uretero-ileal anastomoses on JJ stents with a modified split-nipple technique; urethroneobladder anastomos is performed according to Van Velthoven; hand-sewing of the anterior neobladders wall with barbed suture. RESULTS: All procedures were successfully completed; open conversion was never necessary. Median total operative time (“skin to skin”) was 270 minutes (IQR:255-295). Operative time was < 300 minutes in all patients but two (345 and 350 minutes, respectively). One patient (4,5%) had wound infection (CLavien grade 1), three patients (13.6%) had Clavien grade 2 complications (blood pack trasfusion, urinary tract infection requiring antibiotics, hypoxaemia requiring oxygen treatment), one patient (4.5%) needed urethral catheter replacement in the OR (Clavien grade 3b) and one patient (4.5%) had acute kidney failure requiring temporary dialysis (Clavien grade 4a). Median hopsital stay was 9 days (IQR 8-11). Three patients (13.5%) required readmission after discharge (Candidaemia requiring medical treatment [Clavien grade 2] and nephrostomy tube insertion in two patients [Clavien 3a]). Overall complication rate was 40.1% and overall severe complication incidence was18.2%; 59.5% of patients did not experience any complication. At a median follow-up of 3 months, no patients developed recurrence, daytime continence rate was 59%. CONCLUSIONS: We first report safety and time efficiency in the use of robotic staplers to create orthotopic neobladder. This preliminary report highlights feasibility of this technique and favorable perioperative and functional outcomes.

Robot-assisted Partial Adrenalectomy for the Treatment of Conn's Syndrome: Surgical Technique, and Perioperative and Functional Outcomes

BACKGROUND In the era of minimally invasive surgery, partial adrenalectomy has certainly been underused. We aimed to report surgical technique and perioperative, pathologic, and early functional outcomes of a two-center robot-assisted partial adrenalectomy (RAPA) series. OBJECTIVE To detail surgical technique of RAPA for unilateral aldosterone-producing adenoma (UAPA), and to report perioperative and 1-yr functional outcomes. DESIGN, SETTING, AND PARTICIPANTS Data of 10 consecutive patients who underwent RAPA for UAPA at two centers from June 2014 to April 2017 were prospectively collected and reported. SURGICAL PROCEDURE RAPA was performed using a standardized technique with the da Vinci Si in a three-arm configuration. MEASUREMENTS Baseline and perioperative data were reported. One-year functional outcomes were assessed according to primary aldosteronism surgery outcome guidelines. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS All cases were completed robotically. Median nodule size was 18mm (interquartile range [IQR] 16-20). Intraoperative blood loss was negligible. A single (10%) postoperative Clavien grade 2 complication occurred. Median hospital stay was 3 d (IQR 2-3). Patients became normotensive immediately after surgery (median pre- and postoperative blood pressure: 150/90 and 120/70mmHg, respectively). At both 3-mo and 1-yr functional evaluation, all patients achieved biochemical success (aldosterone level, plasmatic renin activity, and aldosterone-renin ratio within normal range). Complete clinical success was achieved in nine patients, but one required low-dose amlodipine at 6-mo evaluation. At a median follow-up of 30.5 mo (IQR 19-42), neither symptoms nor imaging recurrence was observed. CONCLUSIONS We demonstrated feasibility and safety of RAPA for UAPA; this technique had very low risk of complications and excellent functional results. Increased availability of robotic platform and increasing robotic skills among urologists make RAPA a treatment option with potential for widespread use in urologic community. PATIENT SUMMARY Robot-assisted partial adrenalectomy is a safe, feasible, and minimally invasive surgical approach. Promising perioperative and functional outcomes suggest an increasing adoption of this technique in the near future.

“Ride the Green Light”: Indocyanine Green–marked Off-clamp Robotic Partial Nephrectomy for Totally Endophytic Renal Masses

BACKGROUND Complexity of robot-assisted partial nephrectomy (RAPN) mostly depends on tumor size and location. Totally endophytic renal masses represent a surgical challenge in terms of both intraoperative identification and anatomical dissection. OBJECTIVE To detail a novel technique for marking preoperatively endophytic renal tumors with transarterial superselective intrarenal mass delivery of indocyanine green (ICG)-lipiodol mixture, in order to enhance surgical margins control during purely off-clamp (OC) RAPN with the use of near-infrared fluorescence imaging. DESIGN, SETTING, AND PARTICIPANTS Between June and July 2017, 10 consecutive patients with totally endophytic renal masses underwent preoperative ICG tumor marking immediately followed by RAPN. SURGICAL PROCEDURE Preoperative superselective transarterial delivery of a lipiodol-ICG mixture (1:2 volume ratio) into tertiary-order arterial branches feeding the renal mass prior to transperitoneal OC-RAPN. MEASUREMENTS Clinical data were prospectively collected in our institutional RAPN dataset. Perioperative, pathological, and functional outcomes of RAPN were assessed. RESULTS AND LIMITATIONS Median tumor size was 3cm (interquartile range 2.3-3.8). The median PADUA score was 10 (9-11). Angiographic procedure was successful in all patients. Median operative time was 75min (65-85); median estimated blood loss was 250ml (200-350). No conversion to on-clamp PN or radical nephrectomy was needed. All patients had uneventful perioperative course; median hospital stay was 3 d (2-3). At discharge, median hemoglobin (Hgb) and percent estimated glomerular filtration rate (eGFR) drop were 3.3g/dl (2.1-3.3) and 11% (10-20%), respectively. Surgical margins were negative in all cases. One-year median ipsilateral renal volume and 1-yr eGFR percent decreases were 11.7% (6-20.9%) and 12.2% (5.3-13.7%), respectively. CONCLUSIONS We described a novel technique to simplify challenging RAPN based on ICG superselective transarterial tumor marking. Key benefits include quick intraoperative identification of the mass with improved visualization and real-time control of resection margins. PATIENT SUMMARY Robot-assisted partial nephrectomy (RAPN) for totally endophytic renal masses is a technically demanding surgical procedure, sometimes requiring radical nephrectomy. This novel technique significantly simplified surgical complexity in our Institution. Further studies with larger cohorts are warranted to confirm whether this technique provides relevant intraoperative and functional advantages.

Novel Diagnostic Biomarkers of Prostate Cancer: An Update

OBJECTIVE In recent years, several biomarkers alternative to standard prostate specific antigen (PSA) for prostate cancer (PCa) diagnosis have become available. The aim of this systematic review is to assess the current knowledge about alternative serum and urinary biomarkers for the diagnosis of PCa. MATERIAL AND METHODS A research was conducted in Medline, restricted to English language articles published between December 2014 and June 2018 with the aim to update previously published series on PCa biomarkers. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria were used for selecting studies with the lowest risk of bias. RESULTS Emerging role and actual controversies on serum and urine alternative biomarkers to standard PSA for PCa diagnosis, staging and prognosis assessment, such as prostate health index (PHI), PCA3, ConfirmMDx, Aberrant PSA glycosylation, MiPS, miRNAs are critically presented in the current review. CONCLUSION Although the use of several biomarkers has been recommended or questioned by different international guidelines, larger prospective randomized studies are still necessary to validate their efficacy in PCa detection, discrimination, prognosis and treatment effectiveness. To date, only PHI and 4Kscore have shown clinical relevance for discriminating more aggressive PCa. Furthermore, a new grading classification based on molecular features relevant for PCa risk-stratification and tailoring treatment is still needed.

V12-03 ROBOTIC UTERETAL REIMPLANTATION FOR URETERO-ENTERIC ANASTOMOTIC STRICTURES

tumor identification and characterization. Given their respective strengths and complementary characteristics, we postulate that combining wide-field (PDD and NBI) with microscopic (CLE) imaging technologies will further enhance TURBT. Towards that goal, we report our preliminary experience with multimodal enhanced cystoscopy. METHODS: The study received IRB approval. PDD was performed using hexaminolevulinate (Photocure) in combination with blue light cystoscope (Storz). NBI (Olympus) was performed with an NBIenabled camera head attached to the standard resectoscope. Probebased CLE was performed with fluorescein as the contrast agent along with 2.6 or 0.85 mm endomicroscopes (Cellvizio, Mauna Kea Technologies). Following TURBT with PDD or NBI, the resection bed was imaged with CLE. Imaging features of the resection bed were characterized by 3 urologists and achieved consensus. RESULTS: To date, 10 subjects have undergone multimodal imaging. No adverse events were noted due to the combination of instruments or imaging agents used. Confocal imaging features of the resection bed including elastin fibers (network of thin, interwoven strands), muscle fibers (sheets of straight, connected columns) and perivesical fat (collection of dark, round globules) were observed. Muscularis propria was present in the resected tissue on pathology assessment, confirming adequate resection. Patients are currently undergoing follow-up for cancer recurrence. CONCLUSIONS: We report real-time microscopic inspection of the resection bed to assess for adequate depth of resection with CLE in combination with the macroscopic imaging technologies PDD and NBI. Further studies are needed to determine if multimodal enhanced cystoscopy results in improved TURBT with adequate depth and margins of resection and decreased recurrence rate, which may eventually translate to a decreased need for repeat TURBT.

V8-08 PURELY OFF-CLAMP ROBOTIC PARTIAL NEPHRECTOMY

previously reported Milan vas deferens sling technique by adding reinforcement of under-anastomosis layers during robot-assisted radical prostatectomy, which significantly accelerates early recovery of postoperative urinary continence in cases without nerve-sparing. METHODS: Modified sling technique; Sling suture was made from autologous vas deferens. After putting the vas deferens sling on the sub-urethral perirectal fat, three independent layers were constructed below the urethrovesical anastomosis, and a single anterior layer was made. Then, both ends of the sling were transfixed to Cooper ligaments bilaterally with adequate sling suspension. Between October 2015 and July 2016, consecutive 35 patients who underwent robotassisted radical prostatectomy without nerve-sparing at our institution with a single surgeon were investigated. The patients were classified into two groups: 15 using the sling technique (sling group) and 20 using the non-sling technique with simple posterior reconstruction (nonsling group). Urinary continence defined as 0 or safety 1 pad use daily was compared between the groups. RESULTS: Patients’ characteristics were comparable between the groups. Urinary continence rate significantly improved in the sling group (60.0%, p1⁄40.0365) as compared to the nonsling group (25.0%) at 1 month despite no difference at 3 months (86.7% in the sling group vs. 65.0% in the nonsling group, p1⁄40.1467) postoperatively. Postoperative complications related to sling procedure were not detected. CONCLUSIONS: Despite a small sample size in the singleinstitution study, this sling technique may improve early urinary continence recovery after robot-assisted radical prostatectomy even without nerve-sparing. A larger study is needed to confirm its efficacy.

MP49-08 ON-CLAMP VERSUS OFF-CLAMP PARTIAL NEPHECTOMY: PROPENSITY SCORE MATCHED COMPARISON OF LONG TERM FUNCTIONAL OUTCOMES

clarify the effects of PN on the progression of HT, and investigate its risk factors in a larger cohort of patients with renal tumors. METHODS: Two hundred and ninety-five patients with renal tumors who underwent PN (N 1⁄4 188) or radical nephrectomy (RN) (N 1⁄4 107) between January 2012 and March 2016, and agreed to participate in this study, were enrolled. PN was carried out without vascular clamping in all but five patients (3%). We asked the participants to measure their home blood pressure (BP) in the morning and at bedtime for seven days, and to report these measurements and any use of antihypertensive medications at the time of the follow-up survey. Preand postoperative BP was calculated as the mean of the morning and bedtime BP measured on the day before the surgery, and the mean of all home BP measurements taken for postoperative seven days, respectively. The endpoint of this study was nephrectomy-related HT (NR-HT), defined as postoperative BP 140/90 mmHg with an increase of 20 mmHg from preoperative BP. RESULTS: In the PN and RN patients, the median age was 58 years and 62 years (p 1⁄4 0.042), and tumor size was 2.5 cm and 5.0 cm (p < 0.001), respectively. Before the surgery, 72 (38%) of the PN patients and 42 (39%) of the RN patients were taking antihypertensive medications (p 1⁄4 0.872). The median interval between the surgery and the follow-up survey was seven months. In the PN patients, mean preand postoperative BP was 125/74 mmHg and 129/79 mmHg, respectively, showing both systolic (p < 0.001) and diastolic BP (p < 0.001) increased significantly after the surgery. In the RN patients, there were no significant changes in BP after the surgery. Twenty (11%) of the PN patients and three (3%) of the RN patients developed NR-HT (p 1⁄4 0.009). Antihypertensive medications were added postoperatively in 23 (12%) of the PN patients and six (6%) of the RN patients (p 1⁄4 0.056). Multivariate analysis in the PN patients identified acute kidney injury (odds ratio (OR) 3.30, p 1⁄4 0.034) and higher postoperative peak serum C-reactive protein level (OR 3.01, p 1⁄4 0.026) as independent risk factors for NR-HT. CONCLUSIONS: Postoperative HT was more common in PN patients than in RN patients. Renal parenchymal damage during PN may contribute to the progression of HT.

V12-09 ANATOMIC ROBOT ASSISTED RADICAL CYSTECTOMY IN FEMALE: STEP BY STEP TECHNIQUE

challenging procedure. The need for surgical skills and long operative times have led to concern about its reproducibility. The aim of this video is to illustrate our technique for RARC and totally intracorporeal orthotopic “Padua Ileal Bladder”. METHODS: From August 2012 to February 2014, 45 patients underwent RARC, extended pelvic lymph node dissection and intracorporeal partly stapled neobladder at a single tertiary referral centre. Surgical steps are demonstrated in the accompanying video. Demographics, clinical and pathological data were collected. Perioperative, 2-yr oncologic and 2-yr functional outcomes were reported. RESULTS: Intraoperative transfusion or conversion to open surgery was not necessary in any case and intracorporeal neobladder was successfully performed in all 45 patients. Median operative time was 305 minutes (IQR 282-345). Median estimated blood loss was 210 ml (IQR 50-250). Median hospital stay was 9 days (IQR7e12). The overall incidence of perioperative, 30-d and 180-d complications were 44.4%, 57.8% and 77.8%, respectively, while severe complications occurred in 17.8%, 17.8% and 35.5%, respectively. Two-yr daytime and night-time continence rates were 73.3% and 55.5%, respectively. Twoyr disease free survival, cancer specific survival and overall survival rates were 72.5%, 82.3% and 82.4%, respectively. The small sample size and high caseload of the centre might affect the reproducibility of these results. CONCLUSIONS: Our experience supports the feasibility of totally intracorporeal neobladder following ?RARC. Operative times and perioperative complication rate are likely to be reduced with increasing experience.