James Adshead

‘Trifecta’ outcomes of robot‐assisted partial nephrectomy in solitary kidney: a Vattikuti Collective Quality Initiative (VCQI) database analysis

To analyse the outcomes of robot‐assisted partial nephrectomy (RAPN) in patients with a solitary kidney in a large multi‐institutional database.

Robot-assisted partial nephrectomy in cystic tumours: analysis of the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database

To evaluate the outcomes of robot‐assisted partial nephrectomy (RAPN) in cystic tumours, analysing a large, multi‐institutional, retrospective series of RAPN, as limited data are available about the outcome of RAPN in cystic tumours.

Use of Main Renal Artery Clamping Predominates Over Minimal Clamping Techniques During Robotic Partial Nephrectomy for Complex Tumors

INTRODUCTION Hilar clamping is often performed to facilitate robotic partial nephrectomy (RPN). Minimal clamping techniques may reduce renal ischemia, including early unclamping, selective clamping, and off-clamp RPN. We assess the utilization of clamping techniques in a large international consortium of surgeons performing RPN for complex tumors. METHODS We retrospectively evaluated 721 patients with complex tumors, who underwent RPN at 11 centers worldwide between 2008 and 2014. Complex tumors were defined as renal masses with a nephrometry score >6. Total clamping was defined as complete clamping of the main renal artery. Minimal clamping techniques included early unclamping, selective clamping, and off-clamp RPN. Clamping techniques were additionally assessed in patients with estimated glomerular filtration rate (eGFR) <60 and in patients with a solitary kidney. Two-tailed t-tests (p < 0.05) were used to statistically analyze differences in mean warm ischemia time (WIT). RESULTS Most patients underwent complete clamping (75.1%). Minimal clamping (24.9%) included early unclamping (10.8%), selective clamping (8.7%), and off-clamp (5.4%). Mean WIT of total clamping, selective clamping, and early unclamping was 22.2, 21.2, and 17.3 minutes, respectively. Of patients with an eGFR <60 (n = 90), 26.6% underwent minimal clamping, including 15.5% early unclamping, 4.4% selective clamping, and 6.7% off-clamp. Of patients with solitary kidneys (n = 12), 10 (83%) were performed with total clamping with mean WIT of 14.9 minutes. CONCLUSIONS In this large international series of RPN for complex tumors, most patients underwent total clamping of the main renal artery. Minimal clamping techniques, including early unclamping, selective clamping, and off-clamp techniques, were used in a minority of cases. There was no significant increase in use of minimal clamping, even in patients with chronic kidney disease or solitary kidneys. However, mean WIT was low (<23 minutes) in all patient groups.

Developing a robotic prostatectomy service and a robotic fellowship programme - defining the learning curve.

Introduction: Robotic radical prostatectomy (RRP) is an established treatment for prostate cancer in selected centres with appropriate expertise. We studied our single-centre experience of developing a RRP service and subsequent training of 2 additional surgeons by the initial surgeon and the introduction of United Kingdoms first nationally accredited robotic fellowship training programme. We assessed the learning curve of the 3 surgeons with regard to peri-operative outcomes and oncological results. Patients and Methods: Three hundred consecutive patients underwent RRP between November 2008 and August 2012. Patients were divided into 3 equal groups (Group 1, case 1-100; Group 2, case 101-200; and Group 3, case 201-300). Age, ASA score, preoperative co-morbidities and indications for laparoscopic radical prostatectomy were comparable for all 3 patient groups. Peri-operative and oncological outcomes were compared across all 3 groups to assess the impact of the learning curve for laparoscopic radical prostatectomy. All surgical complications were classified using the Clavien-Dindo system. Results: The mean age was 60.7 years (range 41-74). There was a significant reduction in the mean console time (p < 0.001), operating time (p < 0.001), mean length of hospital stay (p < 0.001) and duration of catheter (p < 0.001) between the 3 groups as the series progressed. The two most important factors predictive of positive surgical margins (PSM) at RRP were the initial prostate specific antigen (PSA) and tumor stage at diagnosis. The overall PSM rate was 26.7%. For T2/T3 tumors the incidence of PSM reduced as the series progressed (Group 1- 22%, Group 2- 32% and Group 3- 26%). The incidence of major complications i.e. grade Clavien-Dindo system score ≤ III was 2% (6/300). Conclusion: RRP is a safe procedure with low morbidity. As surgeons progress through the learning curve peri-operative parameters and oncological outcomes improve. This learning curve is not affected by the introduction of a fellowship-training programme. Using a carefully structured mentored approach, RRP can be safely introduced as a new procedure without compromising patient outcomes.

Robotic Intracorporeal Ileal Conduit Formation: Initial Experience from a Single UK Centre

Objectives. To describe our technique of robotic intracorporeal ileal conduit formation (RICIC) during robotic-assisted radical cystectomy (RARC). To report our initial results of this new procedure. Patients and Methods. Seven male and one female patients underwent RARC with RICIC over a six-month period. Demographic, operative, and outcome data was collected prospectively. Median patient age was 75 years (range 62–78 years). Median followup was 9 months (range 7–14 months). Results. RARC with RICIC was performed successfully in all eight patients. The median total operating time was 360 minutes (range 310–440 minutes) with a median blood loss of 225 mL (range 50–1000 mL). The median length of stay was nine days (range 6–34 days). Four patients (50%) were discharged within seven days. Four patients (50%) experienced one or more complications. This included two Clavien I complications, two Clavien II complications, and two Clavien III complications. Two patients (25%) required transfusion of two units each. To date, there have been no complications associated with the ileal conduit. Conclusion. Whilst being technically challenging, this procedure is safe, feasible, and reproducible. Patients who avoid complication show potential for rapid recovery and early discharge.

The neurovascular structure‐adjacent frozen‐section examination (NeuroSAFE) approach to nerve sparing in robot‐assisted laparoscopic radical prostatectomy in a British setting – a prospective observational comparative study

To evaluate the neurovascular structure‐adjacent frozen‐section examination (NeuroSAFE) technique in a British setting in men undergoing robot‐assisted laparoscopic radical prostatectomy (RALP) .

Effect of Pneumoperitoneum on Renal Function and Physiology in Patients Undergoing Robotic Renal Surgery

Laparoscopic and minimally-invasive robotic access has transformed the delivery of urological surgery. While associated with numerous desirable outcomes including shorter post-operative stay and faster return to preoperative function, these techniques have also been associated with increased morbidity such as reduced renal blood flow and post-operative renal dysfunction. The mechanisms leading to these renal effects complex and multifactorial, and have not been fully elucidated. However they are likely to include direct effects from raised intra-abdominal pressure, and indirect effects secondary to carbon dioxide absorption, neuroendocrine factors and tissue damage from oxidative stress. This review summarises these factors, and highlights the need for further work in this area, to direct novel therapies and guide alterations in technique with the aim of reducing renal dysfunction post-laparoscopic and robotic surgery.

Cardiopulmonary exercise testing in patients undergoing radical cystectomy (open, laparoscopic and robotic)

The use of cardiopulmonary exercise testing (CPET) is gaining popularity as a preoperative functional assessment tool and is a useful adjunct to risk stratification before radical cystectomy. It is important for urologists to understand the indications, contraindications, methodology and different parameters evaluated during CPET assessment and use this information acquired to tailor pre-, intra- and postoperative care in patients undergoing a radical cystectomy. We present a review on the increasing role of CPET in patients undergoing a radical cystectomy.

Conversion of Robot-assisted Partial Nephrectomy to Radical Nephrectomy: A Prospective Multi-institutional Study

OBJECTIVE To assess the incidence and factors affecting conversion from robot-assisted partial nephrectomy (RAPN) to radical nephrectomy. METHODS Between November 2014 and February 2017, 501 patients underwent attempted RAPN by 22 surgeons at 14 centers in 9 countries within the Vattikuti Collaborative Quality Initiative database. Patients were permanently logged for RAPN prior to surgery and were analyzed on an intention-to-treat basis. Multivariable logistic regression with backward stepwise selection of variables was done to assess the factors associated with conversion to radical nephrectomy. RESULTS Overall conversion rate was 25 of 501 (5%). Patients converted to radical nephrectomy were older (median age [interquartile range] 66.0 [61.0-74.0] vs 59.0 [50.0-68.0], P = .012), had higher body mass index (BMI) (median 32.8 [24.9-40.9] vs 27.8 [24.6-31.5] kg/m2, P = .031), higher age-adjusted Charlson comorbidity score (median 6.0 [4.0-7.0] vs 4.0 [3.0-5.0], P <.001), higher American Society of Anesthesiologists score (score ≥3; 13/25 (52.0%) vs 130/476 (27.3%), P = .021), Preoperative estimated glomerular filtration rate (P = .141), clinical tumor stage (P = .145), tumor location (P = .140), multifocality (P = .483), and RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, and anterior/posterior location relative to polar lines) nephrometry score (P = .125) were not significantly different between the groups. On multivariable analysis, independent predictors for conversion were BMI (odds ratio [95% confidence interval]; 1.070 [1.018-1.124]; P = .007) and Charlson score (odds ratio [95% confidence interval]; 1.459 [1.179-1.806]; P = .001). CONCLUSION RAPN was associated with a low rate of conversion. Independent predictors of conversion were BMI and Charlson score. Tumor factors such as clinical stage, location, multifocality, or RENAL score were not associated with increased risk of conversion.

Intraoperative Frozen Section of the Prostate Reduces the Risk of Positive Margin Whilst Ensuring Nerve Sparing in Patients with Intermediate and High-Risk Prostate Cancer Undergoing Robotic Radical Prostatectomy: First Reported UK Series

Introduction: Nerve sparing during robotic radical prostatectomy (RRP) considerably improves post-operative potency and urinary continence as long as it does not compromise oncological outcome. Excision of the neurovascular bundle (NVB) is often performed in patients with intermediate and high risk prostate cancer to reduce the risk of positive surgical margin raising the risk of urinary incontinence and impotence. We present the first UK series outcomes of such patients who underwent an intra-operative frozen section (IOFS) analysis of the prostate during RRP allowing nerve sparing. Patients and Methods: We prospectively analysed the data of 40 patients who underwent an IOFS during RRP at our centre from November 2012 until November 2014. Our IOFS technique involved whole lateral circumferential analysis of the prostate during RRP with the corresponding neurovascular tissue. An intrafascial nerve spare was performed and the specimen was removed intra-operatively via an extension of the 12 mm Autosuture™ camera port without undocking robotic arms. It was then painted by the surgeon and sprayed with “Ink Aid” prior to frozen section analysis. The corresponding NVB was excised if the histopathologist found a positive surgical margin on frozen section. Results: Median time to extract the specimen, wound closure and re-establishment of pneumoperitoneum increased the operative time by 8 min. Median blood loss for IOFS was 130 ± 97 ml vs. 90 ± 72 ml (p = NS). IOFS was not associated with major complications or with blood transfusion. PSM decreased significantly from non-IOFS RRP series of 28.7 to 7.8% (p < 0.05). Intra-operative PSM on the prostate specimen was seen in 8/40 margin analysis (20%) leading to an excision of the contra-lateral nerve bundle. On analysis of the nerve bundle on a paraffin embedded block, 6 nerve bundle matched tumor on the specimen whereas 2 NVB were retrospectively removed unnecessarily in our series. All 40 patients have undetectable PSA at a mean follow up of 21.2 months (SD 7.79). Functional data at 18 months confirms a reduction in the urinary incontinence from 37% in the IOFS group vs 57% in the non-IOFS group (p = NS). IOFS technique has resulted in a significant increase in intravesical nerve sparing in both T2/T3 patients with intermediate and high risk prostate cancer when appropriately counselled and selected (T2 from 100% in the IOFS group versus 67% and T3 from 100% in the IOFS group to 42%) (p < 0.05). Conclusion: Introduction of the IOFS analysis during intrafascial nerve spare RRP has reduced PSM and the rate of urinary incontinence.