Roger Valdivieso

Prediction of Complications Following Partial Nephrectomy: Implications for Ablative Techniques Candidates

BACKGROUND Current guidelines recommend local tumour ablation (LTA) over partial nephrectomy (PN) in nonsurgical candidates; however, objective definitions of these candidates are lacking. OBJECTIVE To identify specific patients who would benefit from LTA more than PN. DESIGN, SETTING, AND PARTICIPANTS A population-based assessment was performed of 2476 patients in the Surveillance Epidemiology and End Results-Medicare database who had cT1a kidney cancer treated with either LTA or PN, between 2000 and 2009. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The outcome of the study was the relevant perioperative complications rate. A multivariable logistic regression model was fitted to predict the risk of complications after PN. Model-derived coefficients were used to calculate the risk of complication in case of PN among patients treated with LTA. Locally weighted scatterplot smoothing method was used to plot the observed complication rate against the predicted risk of complication in case of PN. RESULTS AND LIMITATIONS At multivariable logistic regression, age (odds ratio [OR]: 1.04; p<0.001), Charlson comorbidity index (OR: 1.14; p<0.001), acute kidney injury (OR: 1.91; p=0.04), or chronic kidney disease (OR: 2.16; p=0.002), tumour size (OR: 1.02; p=0.01), and minimally invasive approach (OR: 0.77; p<0.03) emerged as significant predictors of complications. When LTA was chosen over PN, the reduction in the risk of complications was greatest in high-risk patients, intermediate in intermediate-risk patients, and least in low-risk patients. CONCLUSIONS When postoperative complications are evaluated, the benefit of choosing LTA is not the same in all patients diagnosed with T1a kidney cancer. Specifically, patients at high risk of complications in case of PN may benefit the most from LTA and represent ideal LTA candidates. PATIENT SUMMARY Elderly patients at high risk of complications in case of surgical treatment with partial nephrectomy for kidney cancer should be instructed that local tumour ablation might decrease their perioperative morbidity.

Photoselective Vaporization of the Prostate for Benign Prostatic Hyperplasia Using the 180 Watt System: Multicenter Study of the Impact of Prostate Size on Safety and Outcomes

PURPOSE We evaluated photoselective vaporization of the prostate using the GreenLight™ XPS™ 180 W system for benign prostatic hyperplasia treatment in a large multi-institutional cohort at 2 years. We particularly examined safety, outcomes and the re-treatment rate in larger prostates, defined as a prostate volume of 80 cc or greater, to assess the potential of photoselective vaporization of the prostate as a size independent procedure. MATERIALS AND METHODS A total of 1,196 patients were treated at 6 international centers in Canada, the United States, France and England. All parameters were collected retrospectively, including complications, I-PSS, maximum urinary flow rate, post-void residual urine, prostate volume, prostate specific antigen and the endoscopic re-intervention rate. Subgroup stratified comparative analysis was performed according to preoperative prostate volume less than 80 vs 80 cc or greater on transrectal ultrasound. RESULTS Median prostate size was 50 cc in 387 patients and 108 cc in 741 in the prostate volume groups less than 80 and 80 cc or greater, respectively. The rate of conversion to transurethral prostate resection was significantly higher in the 80 cc or greater group than in the less than 80 cc group (8.4% vs 0.6%, p <0.01). I-PSS, quality of life score, maximum urinary flow rate and post-void residual urine were significantly improved compared to baseline at 6, 12 and 24 months of followup without significant differences between the prostate size groups. The re-treatment rate at 2 years reported in 5 of 411 patients was associated with the delivery of decreased energy density (2.1 vs 4.4 kJ/cc) in the group without re-treatment. CONCLUSIONS Photoselective vaporization of the prostate using the XPS 180 W system is safe and efficacious, providing durable improvement in functional outcomes at 2 years independent of prostate size when treated with sufficient energy.

Predictors of early continence following robot-assisted radical prostatectomy

INTRODUCTION Functional outcomes after robot-assisted radical prostatectomy (RARP) greatly influence patient quality of life. Data regarding predictors of early continence, especially 1 month following RARP, are limited. Previous reports mainly address immediate or 3-month postoperative continence rates. We examine preoperative predictors of pad-free continence recovery at the first follow-up visit 1 month after RARP. METHODS Between January 2007 and January 2013, preoperative and follow-up data were prospectively collected for 327 RARP patients operated on by 2 fellowship-trained surgeons (AEH and KCZ). Patient and operative characteristics included age, body mass index (BMI), staging, preoperative prostate-specific antigen (PSA), prostate weight, International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM) score and type of nerve-sparing performed. Continence was defined by 0-pad usage at 1 month follow-up. Univariate and multivariate logistic regression models were used to assess for predictors of early continence. RESULTS Overall, 44% of patients were pad-free 1 month post-RARP. In multivariate regression analysis, age (odds ratio [OR] 0.946, confidence interval [CI] 95%: 0.91, 0.98) and IPSS (OR: 0.953, CI 95%: 0.92, 0.99) were independent predictors of urinary continence 1 month following RARP. Other variables (BMI, staging, preoperative PSA, SHIM score, prostate weight and type of nerve-sparing) were not statistically significant predictors of early continence. Limitations of this study include missing data for comorbidities, patient use of pelvic floor exercises and patient maximal activity. Moreover, patient-reported continence using a 0-pad usage definition represents a semiquantitative and subjective measurement. CONCLUSION In a broad population of patients who underwent RARP at our institution, 44% of patients were pad-free at 1 month. Age and IPSS were independent predictors of early continence after surgery. Men of advanced age and those with significant lower urinary tract symptoms prior to RARP should be counselled on the increased risk of urinary incontinence in the early stages.

Assessment of energy density usage during 180W lithium triborate laser photoselective vaporization of the prostate for benign prostatic hyperplasia. Is there an optimum amount of kilo-Joules per gram of prostate?

To assess the effect of energy density (kJ/mL) applied on adenoma during photoselective vaporization of the prostate (PVP) treatment for benign prostate hyperplasia (BPH) on functional outcomes, prostate‐specific antigen (PSA) reduction and complications.

Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon’s experience

INTRODUCTION We evaluated the average time required to complete individual steps of robotic-assisted radical prostatectomy (RARP) by an expert RARP surgeon. The intent is to help establish a time-based benchmark to aim for during apprenticeship. In addition, we aimed to evaluate preoperative patient factors, which could prolong the operative time of these individual steps. METHODS We retrospectively identified 247 patients who underwent RARP, performed by an experienced robotic surgeon at our institution. Baseline patient characteristics and the duration of each step were recorded. Multivariate analysis was performed to predict factors of prolonged individual steps. RESULTS In multivariable analysis, obesity was a significant predictor of prolonged operative time of: docking (odds ratio [OR] 1.96), urethral division (OR 3.13), and vesico-urethral anastomosis (VUA) (OR 2.63). Prostate volume was also a significant predictor of longer operative time in dorsal vein complex ligation (OR 1.02), bladder neck division (OR 1.03), pedicle control (OR 1.04), urethral division (OR 1.02), and VUA (OR 1.03). A prolonged bladder neck division was predicted by the presence of a median lobe (OR 5.03). Only obesity (OR 2.56) and prostate volume (OR 1.04) were predictors of a longer overall operative time. CONCLUSIONS Obesity and prostate volume are powerful predictors of longer overall operative time. Furthermore, both can predict prolonged time of several individual RARP steps. The presence of a median lobe is a strong predictor of a longer bladder neck division. These factors should be taken into consideration during RARP training.

Multicentre international experience of 532-nm laser photoselective vaporization with GreenLight XPS in men with very large prostates

To describe peri‐operative results, functional outcomes and complications of laser photoselective vaporization, using the GreenLight system, of prostate glands ≥200 mL in volume.

Error reporting from the da Vinci surgical system in robotic surgery: A Canadian multispecialty experience at a single academic centre

INTRODUCTION The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. METHODS A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. RESULTS Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. CONCLUSIONS Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.

Surgery: Urological laparoscopic training—practice makes perfect

Implementing a well-structured laparoscopic training curriculum during urology residency has proven to be challenging. The results of the European Training in Basic Laparoscopic Urological Skills (E-BLUS) examination show low levels of proficiency in laparoscopic techniques for urology residents completing training. What must be done to improve these standards?

Response to: Greenlight® users should move from photoselective vaporization to endoscopic enucleation in larger prostates

Holmium laser enucleation of the prostate (HoLEP) for large prostate glands was first described over a decade ago and compared favourably with open prostatectomy in several randomized trials with excellent efficacy, safety, and longterm durability [2]. From an economical point of view, there are cost benefits for enucleation of large prostate glands using re-useable holmium fibers and morcellator blades. However, despite these advantages, the widespread adoption of HoLEP in the urologic community remains low. For example, within a survey regarding the surgical management of benign prostate hyperplasia (BPH) in the United States, only 8% of the urologist used HoLEP in 2012 [3]. This trend is reflected by the limited exposure to this surgery during residency training, the risk of bladder injury associated with morcellation, and the steep learning curve of this technique [4]. The latter was illustrated in a multicenter prospective study conducted in France assessing the implementation of prospective training structure for HoLEP [5]. There is no doubt that over the past 3 years, there has been a considerable rise in interest as reflected by the increase number of publications in prostate enucleation using energy sources other than the Holmium laser including GreenLight, bipolar, diode, thulium, and even monopolar enucleation [6–8]. Nevertheless, it remains uncertain whether this will translate into widespread adoption of these techniques. In conclusion, enucleation, regardless of the energy used, deserves to be better promoted for treating larger prostates. However, methods for the improvement of the learning curve are warranted to foster its broader utilization and acceptance. For the time being, vapo-resection technique performed by an experienced surgeon remains a fair alternative for treating large glands without the need for morcellation. Dear Editor,

Photoselective vaporization of the prostate with the 180-W XPSGreenlight laser: Five-year experience of safety, efficiency, and functional outcomes

INTRODUCTION Transurethral resection of the prostate (TURP) is still considered the gold standard surgical treatment for symptomatic benign prostatic hyperplasia (BPH). However, photoselective vaporization of the prostate (PVP) has gained widespread global acceptance in national guidelines as a safe and effective alternative option. Nevertheless, further evidence is required to assess the durability of Greenlight PVP. Herein, we report our five years of PVP experience with the Greenlight 180W XPS laser system. METHODS A retrospective analysis was conducted on a prospectively gathered database of 370 consecutively included patients who underwent PVP using Greenlight XPS-180 W laser system (Boston Scientific, Boston, MA, U.S.) performed by a single experienced laser surgeon between 2011 and 2016. Preoperative characteristics, intervention parameters, postoperative functional, uroflowmetry outcomes, and complications were collected. Outcomes are reported over a period of five years. RESULTS Mean age was 68 years, with a mean prostate volume of 78.8 cc (95% confidence interval [CI] 70.9-78.7]). The mean followup was 59.4 months (55.4-63.5). Mean energy, operative time, and energy/cc were 270.2 kJ (255.2-285.2), 62.7 minutes (59.6-65.7), and 3.7 kJ/cc (3.6-3.9), respectively. Compared to preoperative values, International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and post-void residual (PVR) parameters were significantly improved and sustained over the five postoperative years. Of note, only 66 patients (out of 370) had a complete five-year followup. Prostate-specific antigen (PSA) reached nadir at one year, with a drop of 67% from the mean preoperative value of 6.2 ng/mL. Mean IPSS nadir was reached at three years, with a drop of 80.4% (-21.1 points). Similarly, mean quality of life (QoL) score dropped by 82.8% after three years (preoperative mean of 4.7). With respect to mean Qmax, there was an increase by 72.7% (+14.7 mL/s) at one year, reaching the value of 19.9 mL/s. Moreover, mean PVR was 32.8 mL at four years compared to 345 mL preoperatively. At five years followup, PSA, IPSS, QoL, and PVR dropped by 59.7% (3.7 ng/mL), 75.2% (19.7 points), 78.72% (3.7 points), and 84.4% (291.3 mL), respectively. Qmax increased by 12.9 mL/s. Clavien complication rates were low, with bladder neck stenosis observed in seven (1.6%) men. During the five-year followup, only four patients (1%) required BPH surgical re-intervention. CONCLUSIONS This is the first long-term reporting of Greenlight XPS-180W laser system. In experienced hands, the observed outcomes appear to demonstrate that Greenlight XPS-180 W laser system is safe, efficacious, and durable for the treatment of bladder outlet obstruction (BOO) secondary to BPH.