Giovannalberto Pini

Complications in 2200 Consecutive Laparoscopic Radical Prostatectomies: Standardised Evaluation and Analysis of Learning Curves

BACKGROUND Laparoscopic radical prostatectomy (LRP) represents an established treatment modality for localised prostate cancer. OBJECTIVE To report standardised complication rates for LRP, evaluate the development of complication rates over time, and show changes within the learning curves of laparoscopic surgeons. DESIGN, SETTING, AND PARTICIPANTS We conducted a standardised analysis of 2200 consecutive patients who underwent LRP between 1999 and 2008 at a single institution. INTERVENTION LRP was performed using a transperitoneal (n=871) or extraperitoneal (n=1329) retrograde Heilbronn technique. Five surgeons operated on 96% of the patients. MEASUREMENTS Complications were classified according to the modified Clavien system. Total complication rates and changes over time were analysed. Three generations of surgeons were defined for evaluation of learning curves. RESULTS AND LIMITATIONS Minor complications occurred in 21.7% of patients (Clavien 1: 6.8%; Clavien 2: 14.9%); anaemia requiring transfusion (10.4%) dominated. Early reinterventions were necessary in 6.7% of patients (Clavien 3a: 3.6%; Clavien 3b: 1.5%; Clavien 4a: 1.5%; Clavien 4b: 0.1%). Late Clavien 3b complications occurred in 4.7% of patients-most of them anastomotic strictures. Mortality was 0.1% (Clavien 5). There was a significant decrease in overall complication rates over time, resulting predominantly from decreasing Clavien 1-2 events. Learning curves of third-generation surgeons plateaued earlier compared to the first generation (250 vs 700 cases). The limitation of this study is that data concerning comorbidity were not included. CONCLUSIONS LRP is a safe procedure characterised by an acceptable profile of complications. Specifically, few major complications are reported. According to the complication rates, the learning curve of third-generation surgeons is significantly shorter compared to first- and second-generation surgeons.

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.

Role of laparoscopy in reconstructive surgery.

Purpose of review Despite increasing laparoscopic expertise in reconstructive surgery, open procedures still represent the gold standard. Robot-assisted techniques increasingly replace laparoscopy. However, laparoscopy is also developing: by improvement of ergonomics, new instruments, and techniques further reducing access trauma. We evaluated the actual role of laparoscopy focusing on main indications of urologic reconstructive surgery. Recent findings We analysed the current literature (PubMed/Medline) concerning indications, perioperative results, complications, and long-term outcome of laparoscopy for pyeloplasty, ureteral reimplantation, stone surgery, management of vesico-vaginal fistula, sacrocolpopexy (including evidence level). For all indications, laparoscopy provides the advantages of less postoperative pain, blood loss, shorter convalescence, and minimal disfigurement. However, it requires expertise with endoscopic suturing. Most experience (N > 1000) exists with laparoscopic pyeloplasty and sacrocolpopexy which can be considered as valuable options (IIB). Concerning ureteral reimplantation and repair of vesico-vaginal fistula, only a limited number of cases were reported (N < 150) (III). Laparoscopic stone surgery may gain importance particularly in developing countries. Robot-assistance will definitively increase the application of laparoscopic techniques providing optimal ergonomics, whereas the role of single-port surgery will be limited. Summary Laparoscopy will increasingly be used for reconstructive urologic surgery. This trend will be supported by the widespread use of the DaVinci device.

Retroperitoneal Laparoendoscopic Single-Site Surgery: Preliminary Experience in Kidney and Ureteral Indications

The advantages of retroperitoneoscopic technique are well known. We decided to combine this access with the emerging laparoendoscopic single-site surgery (LESS) technique. We present our preliminary data on 11 renoureteral procedures and describe our retroperitoneoscopic LESS technique. As of March 2009, 10 patients were submitted to retroperitoneal LESS and divided into three groups: Group A, 3 patients underwent ureterolithotomy; Group B, 4 patients underwent renal cyst ablation; Group C, 4 patients underwent renal biopsy. Retroperitoneal access was obtained with an optical trocar. After retroperitoneal space blunt dissection, a multichannel port was placed. Standard and bent 5-mm instruments were used; we also used a 5-mm flexible laparoscope as a single procedure in group A. Ten of 11 procedures were completed without conversion; a single case in group A was converted to open surgery. Retroperitoneoscopic LESS is a safe and feasible procedure for renal biopsy and renal cyst ablation, with shorter convalescence time, less postoperative pain, and better cosmetic outcomes. LESS ureterolithotomy was more challenging for the lack of triangulation, resulting in a prolonged convalescence period. In addition, bent laparoscopic instruments are not suitable for retroperitoneal space; the multichannel port leaks carbon dioxide due to the flank position. Therefore LESS pelvic trainer practice is imperative in this case.

Transvesical peritoneoscopy with rigid scope: feasibility study in human male cadaver

BackgroundTransvesical port refers to the method of accessing the abdominal cavity through a natural orifice (i.e., urethra) under endoscopic visualization. Since its introduction in 2006, various reports have been published describing different surgical interventions using a rigid ureteroscope in a porcine model. The aim of this study was to test the access and feasibility of peritoneoscopy by using a rigid ureteroscope in a human male cadaver.MethodsTwo adult male cadavers were used to perform the procedures. A rigid ureteroscope was used for the creation of transvesical access into the peritoneal cavity. Peritoneoscopy, liver biopsy, and identification and manipulation of the ileocecal appendix were performed.ResultsTransvesical access into the peritoneal cavity was quickly established. The rigid ureteroscope easily allowed visualization of the abdominal cavity with good image quality. Liver biopsy and manipulation of ileocecal appendix were carried out without difficulties.ConclusionsPeritoneoscopy, liver biopsy, and ileocecal appendix manipulation using a rigid ureteroscope through a transvesical port is feasible in a cadaver model. The development of a specific rigid scope for the transvesical port might herald a promising future for this NOTES access.

Early Oncologic Failure after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

Purpose: We sought to investigate the prevalence and variables associated with early oncologic failure. Materials and Methods: We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot‐assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot‐assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan‐Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival. Results: A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38–5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00–6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21–3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001). Conclusions: The incidence of early oncologic failure following robot‐assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot‐assisted radical cystectomy.

Laparoscopic Simultaneous Treatment of Peripelvic Renal Cysts and Stones: Case Series

INTRODUCTION Renal multiple peripelvic cysts are often symptomatic. Obstruction of renal hilum and the collecting system leads to hydronephrosis and could promote formation of stones. Managing both entities at the same time needs a new approach to minimize complications and improve success rates. We report for the first time five cases of symptomatic multiple peripelvic cysts and concomitant kidney stones treated by a laparoscopic approach. PATIENTS AND METHODS Between 2003 and 2007 three men and two women, with a median age of 60 years with peripelvic renal cyst and synchronous kidney stones underwent a laparoscopic ablation of cysts, concomitant pyelolithotomy, and stone removal with a flexible auxiliary cystoscope. Mean cyst size was 45 mm (range 15-70 mm). Mean stone size was 25 mm (range 10-33 mm). RESULTS The mean operative time was 173 minutes (range 150-235 minutes). There were neither intraoperative complications nor conversions to open surgery. Mean blood lost was less than 100 mL, and mean hospital stay was 3.2 days (range 3-5 days). After removal of ureteral catheter, patients were asymptomatic and without signs of hydronephrosis. Computed tomography after 6 months showed clearance of all cysts and stones without sign of recurrence. DISCUSSION Laparoscopic management of urolithiasis should be an alternative choice of treatment in some particular and selected indication. Concomitant symptomatic peripelvic cysts and kidney stones could justify simultaneous laparoscopic management. The procedure is technically challenging but safe and effective, and it avoids a staged treatment.

Erectile Function and Oncologic Outcomes Following Open Retropubic and Robot-assisted Radical Prostatectomy: Results from the LAParoscopic Prostatectomy Robot Open Trial

BACKGROUND Whether surgeons perform better utilising a robot-assisted laparoscopic technique compared with an open approach during prostate cancer surgery is debatable. OBJECTIVE To report erectile function and early oncologic outcomes for both surgical modalities, stratified by prostate cancer risk grouping. DESIGN, SETTING, AND PARTICIPANTS In a prospective nonrandomised trial, we recruited 2545 men with prostate cancer from seven open (n=753) and seven robot-assisted (n=1792) Swedish centres (2008-2011). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Clinometrically-validated questionnaire-based patient-reported erectile function was collected before, 3 mo, 12 mo, and 24 mo after surgery. Surgeon-reported degree of neurovascular-bundle preservation, pathologist-reported positive surgical margin (PSM) rates, and 2-yr prostate-specific antigen-relapse rates were measured. RESULTS AND LIMITATIONS Among 1702 preoperatively potent men, we found enhanced erectile function recovery for low/intermediate-risk patients in the robot-assisted group at 3 mo. For patients with high-risk tumours, point estimates for erectile function recovery at 24 mo favoured the open surgery group. The degree of neurovascular bundle preservation and erectile function recovery were greater correlated for robot-assisted surgery. In pT2 tumours, 10% versus 17% PSM rates were observed for open and robot-assisted surgery, respectively; corresponding rates for pT3 tumours were 48% and 33%. These differences were associated with biochemical recurrence in pT3 but not pT2 disease. The study is limited by its nonrandomised design and relatively short follow-up. CONCLUSIONS Earlier recovery of erectile function in the robot-assisted surgery group in lower-risk patients is counterbalanced by lower PSM rates for open surgeons in organ-confined disease; thus, both open and robotic surgeons need to consider this trade-off when determining the plane of surgical dissection. Robot-assisted surgery also facilitates easier identification of nerve preservation planes during radical prostatectomy as well as wider dissection for pT3 cases. PATIENT SUMMARY For prostate cancer surgery, an open operation reduces erection problems in high-risk cancers but has higher relapse rates than robotic surgery. Relapse rates appear similar in low/intermediate-risk cancers and the robot appears better at preserving erections in these cases.

Outcomes of Intracorporeal Urinary Diversion after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

Purpose: This study aimed to provide an update and compare perioperative outcomes and complications of intracorporeal and extracorporeal urinary diversion following robot‐assisted radical cystectomy using data from the multi‐institutional, prospectively maintained International Robotic Cystectomy Consortium database. Materials and Methods: We retrospectively reviewed the records of 2,125 patients from a total of 26 institutions. Intracorporeal urinary diversion was compared with extracorporeal urinary diversion. Multivariate logistic regression models using stepwise variable selection were fit to evaluate preoperative, operative and postoperative predictors of intracorporeal urinary diversion, operative time, high grade complications and 90‐day hospital readmissions after robot‐assisted radical cystectomy. Results: In our cohort 1,094 patients (51%) underwent intracorporeal urinary diversion. These patients demonstrated shorter operative time (357 vs 400 minutes), less blood loss (300 vs 350 ml) and fewer blood transfusions (4% vs 19%, all p <0.001). They experienced more high grade complications (13% vs 10%, p = 0.02). Intracorporeal urinary diversion use increased from 9% of all urinary diversions in 2005 to 97% in 2015. Complications after this procedure decreased significantly with time (p <0.001). On multivariable analysis higher annual cystectomy volume (OR 1.02, 95% CI 1.01–1.03, p <0.002), year of robot‐assisted radical cystectomy (2013–2016 OR 68, 95% CI 44–105, p <0.001) and American Society of Anesthesiologists® score less than 3 (OR 1.75, 95% CI 1.38–2.22, p <0.001) were associated with undergoing intracorporeal urinary diversion. The procedure was associated with a shorter operative time of 27 minutes (p = 0.001). Conclusions: The use of intracorporeal urinary diversion has increased in the last decade. A higher annual institutional volume of robot‐assisted radical cystectomy was associated with intracorporeal urinary diversion as well as with shorter operative time. Although intracorporeal urinary diversion was associated with higher grade complications than extracorporeal urinary diversion, they decreased with time.

Development of a patient and institutional-based model for estimation of operative times for robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium

To design a methodology to predict operative times for robot‐assisted radical cystectomy (RARC) based on variation in institutional, patient, and disease characteristics to help in operating room scheduling and quality control.