S. Crivellaro

Analysis of radical cystectomy and urinary diversion complications with the Clavien classification system in an Italian real life cohort

INTRODUCTIONnStandardized methods of reporting complications after radical cystectomy (RC) and urinary diversions (UD) are necessary to evaluate the morbidity associated with this operation to evaluate the modified Clavien classification system (CCS) in grading perioperative complications of RC and UD in a real life cohort of patients with bladder cancer.nnnMATERIALS AND METHODSnA consecutive series of patients treated with RC and UD from April 2011 to March 2012 at 19 centers in Italy was evaluated. Complications were recorded according to the modified CCS. Results were presented as complication rates per grade. Univariate and binary logistic regression analysis were used for statistical analysis.nnnRESULTSnnnnRESULTS AND LIMITATIONSn467 patients were enrolled. Median age was 70 years (range 35-89). UD consisted in orthotopic neobladder in 112 patients, ileal conduit in 217 patients and cutaneous ureterostomy in 138 patients. 415 complications were observed in 302 patients and were classified as Clavien type I (109 patients) or II (220 patients); Clavien type IIIa (45 patients), IIIb (22 patients); IV (11 patients) and V (8 patients). Patients with cutaneous ureterostomy presented a lower rate (8%) of CCS type ≥IIIa (p = 0.03). A longer operative time was an independent risk factor of CCS ≥III (OR: 1.005; CI: 1.002-1.007 per minute; p = 0.0001).nnnCONCLUSIONSnIn our study, RC is associated with a significant morbidity (65%) and a reduced mortality (1.7%) when compared to previous experiences. The modified CCS represents an easily applicable tool to classify the complications of RC and UD in a more objective and detailed way.

Open versus robotic-assisted partial nephrectomy: a multicenter comparison study of perioperative results and complications

PurposeTo compare surgical results, morbidity and positive surgical margins rate of patients undergoing robotic partial nephrectomy (RPN) versus open partial nephrectomy (OPN).MethodsThis is an observational multicenter study promoted by the “Associazione GIovani Laparoscopisti Endoscopisti” (AGILE) no-Profit Foundation, which involved six Italian urologic centers. All clinical, surgical, and pathological variables of patients treated with OPN or RPN for renal tumors were gathered in a prospectively maintained database. Tumor nephrometry was measured with PADUA score, and complications were stratified with modified Clavien system. Differences between RPN and OPN group were assessed with univariate analysis. Perioperative variables independently associated with complications were assessed with multivariate analysis.ResultsA total of 198 and 105 patients were enrolled in OPN and RPN group, respectively. Both had similar demographics, indications to surgery, tumor nephrometry, renal function, WIT (18.7 vs. 18.2xa0min; pxa0=xa0NS), positive margin rate (5.6 vs. 5.7xa0%; pxa0=xa0NS), intraoperative complications, and postoperative medical complications. Compared to OPN, RPN group was significantly more morbid (pxa0=xa00.04), included tumors with smaller size (pxa0=xa00.002), had longer operative time (pxa0<xa00.001), lower blood loss, surgical postoperative complications (5.7 vs. 21.2xa0%, pxa0<xa00.001), Clavien 3–4 surgical complications (1 vs. 9.1xa0%, pxa0=xa00.001), and shorter hospitalization. The surgical approach resulted independently correlated with surgical complications on multivariate analysis.ConclusionIn the present series, RPN was associated with a significant reduction of blood loss, surgical complications, including the reintervention rate for urinary fistula and postoperative bleeding, and with a shorter hospitalization.

Cost effectiveness and robot-assisted urologic surgery: does it make dollars and sense?

INTRODUCTIONnThe introduction of the robotic surgical platform has led to distinct changes in practice patterns and the utilization of minimally invasive surgery in urology. While use of the robotic system is associated with improvements in perioperative outcomes such as estimated blood loss and hospital stay, there are significant fixed and variable costs with the purchase, maintenance and use of the robotics system that has led many authors to investigate the cost effectiveness of robotic urologic surgery. We sought to examine the best current available evidence for the cost effectiveness of robotic urologic surgery.nnnEVIDENCE ACQUISITIONnComprehensive electronic literature searches were conducted without language restriction to identify reports of published studies within PubMed/Medline, SCOPUS and Web of Science. Relevant articles were examined and reference lists cross referenced to find additional pertinent publications.nnnEVIDENCE SYNTHESISnPubMed literature searches of robot urology cost (304 articles) robotic prostatectomy cost (215 articles), robotic nephrectomy cost (87 articles), robotic cystectomy cost (44 articles) and robotic pyeloplasty cost (41 articles) were initially reviewed in abstract form to find appropriate articles for inclusion. Given that robotic cystectomy (559 articles), robotic pyeloplasty (344 articles) robotic retroperitoneal lymph node dissection (59 articles) are less frequently performed than robotic prostatectomy, all available articles published from January 1st 2000 until July 31st 2016 were reviewed for potential inclusion. After excluding duplicates, appropriate articles were pulled for full text review. 49 articles were used for the final analysis.nnnCONCLUSIONSnThe available literature on the cost effectiveness of robotic urologic surgery is somewhat limited by heterogeneity of research methods, local cost variations and methods for determining costs associated with surgical outcomes. The introduction of the robotic surgical platform has led to a dramatic change in the availability and utilization of laparoscopic surgery and is associated with both favorable perioperative outcomes as well as significantly greater fixed costs related to instrumentation and equipment expenses. Well-designed trials comparing open and robotic approaches in the contemporary era of widespread robotic adoption with quality of life and validated economic metrics will be necessary to provide evidence for continued use of this valuable technology.

Margini chirurgici positivi dopo prostatectomia radicale mini-invasiva: studio multicentrico

Aim The aim of our study is to evaluate the status of positive margins (PSMs) comparing their incidence between aparoscopic radical prostatectomy (LRP) and robot assisted radical prostatectomy (RARP) in centers with medium case-load (50–150 cases/year). We also analyzed the correlations between surgical technique, nerve-sparing approach (NS), and incidence of PSMs, stratifying our results by pathological stage. Materials and methods We analyzed 1992 patients who underwent RP in various urologic centers. We evaluated the incidence of PSMs, and then we compared the stage-related incidence of PSMs, for both the techniques. Results We did not find a statistically significant difference between the two surgical modalities in the study regarding the overall incidence of PSMs. Conclusions In our retrospective study, we did not find any difference in terms of PSMs in RARP versus LRP. Our PSMs were not negligible, particularly in pT3 stages, compared with high-volume centers; surgical experience and patients selection can be a possible explanation.

Margini chirurgici positivi dopo prostatectomia radicale mini-invasiva: studio multicentrico [Positive surgical margin status after minimally invasive radical prostatectomy: a multicenter study]

Aim The aim of our study is to evaluate the status of positive margins (PSMs) comparing their incidence between aparoscopic radical prostatectomy (LRP) and robot assisted radical prostatectomy (RARP) in centers with medium case-load (50–150 cases/year). We also analyzed the correlations between surgical technique, nerve-sparing approach (NS), and incidence of PSMs, stratifying our results by pathological stage. Materials and methods We analyzed 1992 patients who underwent RP in various urologic centers. We evaluated the incidence of PSMs, and then we compared the stage-related incidence of PSMs, for both the techniques. Results We did not find a statistically significant difference between the two surgical modalities in the study regarding the overall incidence of PSMs. Conclusions In our retrospective study, we did not find any difference in terms of PSMs in RARP versus LRP. Our PSMs were not negligible, particularly in pT3 stages, compared with high-volume centers; surgical experience and patients selection can be a possible explanation.

[Positive surgical margin status after minimally invasive radical prostatectomy: a multicenter study]

Aim The aim of our study is to evaluate the status of positive margins (PSMs) comparing their incidence between aparoscopic radical prostatectomy (LRP) and robot assisted radical prostatectomy (RARP) in centers with medium case-load (50–150 cases/year). We also analyzed the correlations between surgical technique, nerve-sparing approach (NS), and incidence of PSMs, stratifying our results by pathological stage. Materials and methods We analyzed 1992 patients who underwent RP in various urologic centers. We evaluated the incidence of PSMs, and then we compared the stage-related incidence of PSMs, for both the techniques. Results We did not find a statistically significant difference between the two surgical modalities in the study regarding the overall incidence of PSMs. Conclusions In our retrospective study, we did not find any difference in terms of PSMs in RARP versus LRP. Our PSMs were not negligible, particularly in pT3 stages, compared with high-volume centers; surgical experience and patients selection can be a possible explanation.

259 Robotic-assisted versus open partial nephrectomy: A prospective multicenter comparison study of perioperative outcomes (AGILE project)

1University of Florence, Dept. of Urology, Florence, Italy, 2University of Brescia, Dept. of Urology, Brescia, Italy, 3Hospital of Bassano Del Grappa, Dept. of Urology, Bassano del Grappa, Italy, 4University of Udine, Dept. of Urology, Udine, Italy, 5Hospital of Abano Terme, Dept. of Urology, Abano Terme, Italy, 6University of Milan, Dept. of Urology, Milan, Italy, 7Hospital Carlo Poma, Dept. of Urology, Mantova, Italy, 8Hospital “Maggiore Della Carità”, Dept. of Urology, Novara, Italy