P. Schatteman

Impact of the Learning Curve on Perioperative Outcomes in Patients Who Underwent Robotic Partial Nephrectomy for Parenchymal Renal Tumours

BACKGROUND Robot-assisted partial nephrectomy (RAPN) is an emerging, minimally invasive technique to treat patients with small renal masses. OBJECTIVE To evaluate the impact of the learning curve on perioperative outcomes such as operative times and warm ischaemia times (WIT), blood loss, overall complications, and renal function impairment in patients who underwent RAPN. DESIGN, SETTING, AND PARTICIPANTS We collected prospectively the clinical and pathologic records of 62 consecutive patients who underwent RAPN between September 2006 and November 2009 for renal tumours at a nonacademic teaching institution by a single surgeon with extensive prior robotic experience. INTERVENTIONS The surgeon used transperitoneal RAPN with excision of an adequate rim of healthy peritumour renal parenchyma. MEASUREMENTS Perioperative parameters, pathologic outcome, and short-term outcomes for renal function were recorded. The effects of the learning curve on the previous reported perioperative and functional outcomes was studied. RESULTS AND LIMITATIONS The mean pathologic tumour size was 2.8 +/-1.3 cm. A pelvicaliceal repair was needed in 33 cases (53%). The mean console time was 91 +/-33 min (range: 52-180), with a mean WIT of 20 +/- 7 min (range: 9-40). Warm ischaemia (<20 min) and console times were optimised after the first 30 (p<0.001) and 20 cases (p<0.001), respectively. Pathologic results yielded a positive surgical margin (PSM) rate of 2%. Mean creatinine level changed from a baseline value of 1.02 +/- 0.38 mg/dl to 1.1 +/- 0.7 mg/dl 3 mo after surgery. Estimated glomerular filtration rate changed from a baseline value of 81.17 +/- 29 to 80.5 +/- 29 (millilitres per minute per 1.73 m(2)) 3 mo postoperatively. CONCLUSIONS RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. Specifically, in the hands of a surgeon with extensive robotic experience, RAPN requires a short learning curve to reach WIT < 20 min, console times < 100 min, limited blood loss, and acceptable overall complication rates.

Long-term biochemical recurrence rates after robot-assisted radical prostatectomy: analysis of a single-center series of patients with a minimum follow-up of 5 years.

OBJECTIVE To address the long-term biochemical recurrence (BCR)-free survival rates of patients treated with robotic-assisted laparoscopic prostatectomy (RALP) with a minimum follow-up of 5 years. MATERIALS AND METHODS Prospectively collected data of 184 patients treated with RALP at a single institution were analyzed. Kaplan-Meier and life tables analyses targeted the rates of BCR according to pathologic parameters. Cox regression analyses addressed predictors of BCR. RESULTS Median follow-up was 67.5 months. One and 10 patients died of prostate cancer (PCa) and other causes, respectively. Mean time to BCR was 83.8 months. The 3-, 5-, and 7-year BCR-free survival rates were 94%, 86%, and 81%, respectively. These rates were 97%, 93%, and 85% for pT2 disease; 94%, 84%, and 84% for pT3a; and 69%, 43%, and 43% for pT3b (P<.001). The same figures were 97%, 90%, and 88% for Gleason sum 6 or lower; 90%, 86%, and 75% for Gleason sum 7; and 85%, 65%, and 65% for Gleason sum 8-10 (P=.01). At univariable analyses, prostate-specific antigen, pathologic Gleason score, and presence of extracapsular extension, seminal vesicle invasion, and adjuvant radiotherapy were significantly associated with BCR. At multivariable analysis, the presence of seminal vesicle invasion and the presence of Gleason sum 8-10 represented independent predictors of BCR (HR=5.14; P=.004 and HR=3.04; P=.04, respectively). CONCLUSION We report the longest available follow-up in RALP patients. RALP represents an oncologically effective procedure. Our oncological results support the increasing diffusion of RALP for the treatment of organ-confined PCa.

Long‐term evaluation of survival, continence and potency (SCP) outcomes after robot‐assisted radical prostatectomy (RARP)

To report combined oncological and functional outcome in a series of patients who underwent robot‐assisted radical prostatectomy (RARP) for clinically localised prostate cancer in a single European centre after 5‐year minimum follow‐up according to survival, continence and potency (SCP) outcomes.

Robot-assisted Simple Prostatectomy for Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Enlargement: Surgical Technique and Outcomes in a High-volume Robotic Centre

BACKGROUND Robot-assisted simple prostatectomy (RASP) is a minimally invasive procedure for treatment of patients with lower urinary tract symptoms (LUTS) due to large benign prostatic enlargement (BPE). OBJECTIVE To present the perioperative and short-term functional outcomes of RASP in a large series of patients with LUTS due to BPE treated in a high-volume referral center. DESIGN, SETTING, AND PARTICIPANTS We retrospectively collected data for 67 consecutive patients who underwent RASP from October 2008 to August 2014. SURGICAL PROCEDURE RASP was performed using a Da Vinci S or Si system with a transvesical approach. MEASUREMENTS Complications were graded according to the Clavien-Dindo system. Continuous variables are reported as median and interquartile range (IQR). Comparison of preoperative and postoperative outcomes was assessed by Wilcoxon test. A two-sided value of p<0.05 was considered statistically significant. RESULTS AND LIMITATIONS The median preoperative prostate volume was 129ml (IQR 104-180). For the 45 patients who did not have an indwelling catheter, the median preoperative International Prostate Symptom Score (IPSS) was 25 (20.5-28), the median maximum flow rate (Qmax) was 7ml/s (IQR 5-11), and the median post-void residual volume (PVRV) was 73ml (IQR 40-116). The median operative time was 97min (IQR 80-127) and the median estimated blood loss was 200ml (IQR 115-360). The postoperative complication rate was 30%, including three cases (4.5%) with grade 3b complications (major bleeding requiring cystoscopy and coagulation). The median catheterization time was 3 d (IQR 2-4) and the median length of stay was 4 d (IQR 3-5). The median follow-up was 6 mo (IQR 2-12). At follow-up, the median IPSS was 3 (IQR 0-8), the median Qmax was 23ml/s (IQR 16-35), and the median PVRV was 0ml (IQR 0-36) (all p<0.001 vs baseline values). The retrospective design is the major study limitation. CONCLUSIONS Our data indicate good perioperative outcomes, an acceptable risk profile, and excellent improvements in patient symptoms and flow scores at short-term follow-up following RASP. PATIENT SUMMARY We analyzed the perioperative and functional outcomes of robot-assisted simple prostatectomy in the treatment of male patients with lower urinary tract symptoms due to large prostatic adenoma. The procedure was associated with a relatively low risk of complications and excellent functional outcomes, including considerable improvements in symptoms and flow performance. We can conclude that the procedure is a valuable option in the treatment of such patients. However, comparative studies evaluating the efficacy of the procedure in comparison with endoscopic treatment of large prostatic adenomas are needed.

Robot-assisted Sacrocolpopexy for Pelvic Organ Prolapse: Surgical Technique and Outcomes at a Single High-volume Institution

BACKGROUND Pelvic organ prolapse (POP) represents a common female pelvic floor disorder that has a serious impact on quality of life. Several types of procedures with different surgical approaches have been described to correct these defects, but the optimal management is still debated. OBJECTIVE To describe our surgical technique of robot-assisted sacrocolpopexy (RASC) for POP and to assess its safety and long-term outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of the medical records of 95 consecutive patients who underwent RASC for POP at our centre from April 2006 to December 2011 was performed. SURGICAL PROCEDURE RASC with use of polypropylene meshes was performed in all cases using a standardised technique with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in a four-arm configuration. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Clinical data were collected in a dedicated database. Intraoperative variables, postoperative complications, and outcomes of RASC were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS Median operative time was 101 min. No conversion to open surgery was needed. One vaginal and two bladder injuries occurred and were repaired intraoperatively. Only one Clavien grade 3 postoperative complication was observed (bowel obstruction treated laparoscopically). At a median follow-up of 34 mo, persistent POP was observed in four cases (4.2%). One mesh erosion occurred and required robot-assisted removal of the mesh. Ten (10.5%) patients complained de novo urgency after RASC, which resolved in the first few weeks after surgery. No significant de novo bowel or sexual symptoms were reported. CONCLUSIONS Our technique of RASC for correction of POP is safe and effective, with limited risk of complications and good long-term results in the treatment of all types of POP. The robotic surgical system facilitates precise and accurate placement of the meshes with short operative time, thereby favouring wider diffusion of minimally invasive treatment of POP. PATIENT SUMMARY We studied the treatment of patients with vaginal prolapse by using a robot-assisted surgical technique to fix the vaginal wall with a synthetic mesh. This technique was found to be safe and effective, with limited risk of complications and good long-term results.

Surgery Illustrated – Surgical Atlas Robotic radical cystectomy in the male

According to the European Association of Urology guidelines, radical cystectomy (RC) is the standard treatment for localized muscleinvasive bladder cancer T2-T4a, N0-Nx, M0. Other indications include high-risk and recurrent superficial tumours, BCG-resistant Tis, T1G3, as well as extensive papillary disease that cannot be controlled with transurethral resection and intravesical therapy alone. Salvage cystectomy is indicated when conservative therapy fails, recurrences after bladder-sparing treatments, non-urothelial carcinomas (these tumours respond poorly to chemoand radiotherapy), and as a purely palliative intervention, e.g. for fistula formation, pain or recurrent macrohaematuria.

Early Catheter Removal after Robot-assisted Radical Prostatectomy: Surgical Technique and Outcomes for the Aalst Technique (ECaRemA Study)

BACKGROUND Robot-assisted radical prostatectomy (RARP) is a widespread option for the treatment of patients with clinically localised prostate cancer. Modifications in the surgical technique may help to further improve functional outcomes. OBJECTIVE To assess the outcome of early catheter removal 48h after surgery, as opposed to standard catheter removal 6 d after surgery following RARP, using a newly developed surgical technique for posterior reconstruction and anastomosis (Aalst technique). DESIGN, SETTING, AND PARTICIPANTS Patients scheduled for RARP were prospectively scheduled for early catheter removal at postoperative d 2 (group A, n=37) and standard catheter removal at postoperative d 6 (group B, n=37). SURGICAL PROCEDURE RARP was performed using the Da Vinci Si system. The Aalst technique for the urethro-vesical anastomosis including posterior reconstruction was used as previously described. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was spontaneous voiding after catheter removal. Secondary endpoints were rate of anastomotic urinary leakage after catheter removal, presence and severity of urethral, perineal, and abdominal pain, as well as patients bother after catheter removal using visual analogue scale (VAS) scores. Rate and severity of urinary incontinence after catheter removal were assessed using the International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms Module (ICIQ-MLUTS) questionnaire. RESULTS AND LIMITATIONS There was no significant difference between the groups with regard to baseline and perioperative parameters, as well as pathological features; however, significantly more patients underwent bilateral nerve-sparing procedures in group A (34 vs 23, p=0.008). After catheter removal, patients in both groups showed spontaneous voiding, whereas only 11% and 8% of the patients in group A and group B experienced urinary retention after catheter removal (p=0.7). Patients in group B had significantly higher maximum flow rates, but lower voided volumes after catheter removal in comparison with patients in group A (21ml/s vs 10ml/s, p≤0.001 and 170ml vs 200ml, p≤0.001, respectively). ICIQ-MLUTS questionnaire and VAS scores showed no significant differences between the groups at any time point. CONCLUSIONS The Aalst technique allows the removal of catheters 2 d after RARP and results in spontaneous voiding. Early removal showed no increased rate of urinary leakage, no negative impact on short-term continence and on perineal, urethral or penile pain, and no increase in urinary retention rates. Future studies have to confirm these results with longer follow-up including detailed parameters on return to daily activity. PATIENT SUMMARY We provide evidence that it is possible to remove the bladder catheter as early as 2 d after robot-assisted radical prostatectomy without any negative effects on voiding and pain parameters. Thus, leaving the hospital early without a catheter in place could represent a significant and relevant benefit for the patient.

Robotic assistance in urological microsurgery: initial report of a successful in-vivo robot-assisted vasovasostomy

During recent years many urologists have been convinced of the advantages of robot-assisted, minimally invasive urological procedures. Because microscope-assisted vasovasostomy is a rather uncommon procedure, most urologists lack microsurgical experience. Use of the da Vinci robotic system (Intuitive Surgical, Mountain View, CA, USA) virtually eliminates the microsurgical challenge of tremor, limited dexterity, and miniaturized instrumentation. Different centres have investigated the use of robotic assistance in vasovasal anastomosis in animal and human ex-vivo models. According to the current literature we are the first European centre to report a successful in-vivo robot-assisted vasovasostomy using the da Vinci robotic system.

Abiraterone acetate post-docetaxel for metastatic castration-resistant prostate cancer in the Belgian compassionate use program

BACKGROUND Abiraterone acetate (AA) is licensed for treating metastatic castration-resistant prostate cancer (mCRPC). Real-world data on oncological outcome after AA are scarce. The current study assesses efficacy and safety of AA in mCRPC patients previously treated with docetaxel who started treatment during the Belgian compassionate use program (January 2011-July 2012). PATIENTS AND METHODS Records from 368 patients with mCRPC from 23 different Belgian hospitals who started AA 1000mg per day with 10mg prednisone or equivalent were retrospectively reviewed (September 2013-December 2014). Prostate-specific antigen (PSA) response (decrease≥50%), time to PSA progression (increase>50% over PSA nadir in case of PSA response/>25% in absence of PSA response), time to radiographic progression (on bone scans or for soft tissue lesions using Response Evaluation Criteria In Solid Tumors 1.1), overall survival and adverse event rate (Common Terminology Criteria for Adverse Events v4.03) were analyzed. Kaplan-Meier statistics were applied. RESULTS Overall, 92 patients (25%) had an Eastern Cooperative Oncology Group performance status≥2. Median age was 73 years, median PSA was 103ng/dl. PSA response was observed in 131 patients (37.4%). Median time to PSA and radiographic progression was 4.1 months (95% CI: 3.6-4.6) and 5.8 months (5.3-6.4), respectively. Median overall survival was 15.1 months (13.6-16.6). Most common grade 3 to 4 adverse events were anemia (13.9%), hypokalemia (7.3%), fatigue (6.8%), and pain (6.3%). Median duration of AA treatment was 5.3 months (interquartile range: 2.8-10.3). The main study limitation is its retrospective design. CONCLUSIONS These real-world data on post-docetaxel AA efficacy are in line with the COU-AA-301 trial. Importantly, incidence of severe anemia and hypokalemia is up to 50% higher than reported in previous studies.

Port site metastasis in prostate cancer.

Port-site metastasis of prostatic adenocarcinoma is rare and usually associated with poor prognosis. We report a case of a young man with a rising prostate-specific antigen (PSA) 4.5 years after robot-assisted laparoscopic prostatectomy (RALP) and extended pelvic lymphadenectomy (ePLND) for a Gleason 7 (4+3) prostate cancer (pT3b pN0 cM0). Choline positron emission tomography-computed tomography (PET-CT) demonstrated a PET positive subcutaneous recurrence in a previous trocar site accompanied by a PET positive ipsilateral inguinal lymph node. Excision of both lesions was performed, confirming the diagnosis of metastatic prostate cancer. The patients PSA dropped significantly postoperatively enabling postponement of androgen deprivation treatment up to this date. The etiology of port-site metastasis is multifactorial, including patient and surgery related factors. Such metastases have been scarcely reported following ePLND with or without RALP. Certain surgical precautions can be made to prevent the occurrence. We summarize previously reported mechanisms of development and possible precautionary measures.