Senthil Nathan

Robot-assisted intracorporeal pyramid neobladder

To describe a robot‐assisted intracorporeal pyramid neobladder reconstruction technique and report operative and perioperative metrics, postoperative upper tract imaging, neobladder functional outcomes, and oncological outcomes.

Medium-term Outcomes after Whole-gland High-intensity Focused Ultrasound for the Treatment of Nonmetastatic Prostate Cancer from a Multicentre Registry Cohort

BACKGROUNDnHigh-intensity focused ultrasound (HIFU) is a minimally-invasive treatment for nonmetastatic prostate cancer.nnnOBJECTIVEnTo report medium-term outcomes in men receiving primary whole-gland HIFU from a national multi-centre registry cohort.nnnDESIGN, SETTING, AND PARTICIPANTSnFive-hundred and sixty-nine patients at eight hospitals were entered into an academic registry.nnnINTERVENTIONnWhole-gland HIFU (Sonablate 500) for primary nonmetastatic prostate cancer. Redo-HIFU was permitted as part of the intervention.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnOur primary failure-free survival outcome incorporated no transition to any of the following: (1) local salvage therapy (surgery or radiotherapy), (2) systemic therapy, (3) metastases, or (4) prostate cancer-specific mortality. Secondary outcomes included adverse events and genitourinary function.nnnRESULTS AND LIMITATIONSnMean age was 65 yr (47-87 yr). Median prostate-specific antigen was 7.0 ng/ml (interquartile range 4.4-10.2). National Comprehensive Cancer Network low-, intermediate-, and high-risk disease was 161 (28%), 321 (56%), and 81 (14%), respectively. One hundred and sixty three of 569 (29%) required a total of 185 redo-HIFU procedures. Median follow-up was 46 (interquartile range 23-61) mo. Failure-free survival at 5 yr after first HIFU was 70% (95% confidence interval [CI]: 64-74). This was 87% (95% CI: 78-93), 63% (95% CI: 56-70), and 58% (95% CI: 32-77) for National Comprehensive Cancer Network low-, intermediate-, and high-risk groups, respectively. Fifty eight of 754 (7.7%) had one urinary tract infection, 22/574 (2.9%) a recurrent urinary tract infection, 22/754 (3%) epididymo-orchitis, 227/754 (30%) endoscopic interventions, 1/754 (0.13%) recto-urethral fistula, and 1/754 (0.13%) osteitis pubis. Of 206 known to be pad-free pre-HIFU, 183/206 (88%) remained pad free, and of 236 with good baseline erectile function, 91/236 (39%) maintained good function. The main limitation is lack of long-term data.nnnCONCLUSIONSnWhole-gland HIFU is a repeatable day-case treatment that confers low rates of urinary incontinence. Disease control at a median of just under 5 yr of follow-up demonstrates its potential as a treatment for nonmetastatic prostate cancer. Endoscopic interventions and erectile dysfunction rates are similar to other whole-gland treatments.nnnPATIENT SUMMARYnIn this report we looked at the 5-yr outcomes following whole-gland high-intensity focused ultrasound treatment for prostate cancer and found that cancer control was acceptable with a low risk of urine leakage. However, risk of erectile dysfunction and further operations was similar to other whole-gland treatments like surgery and radiotherapy.

Achieving Quality Assurance of Prostate Cancer Surgery During Reorganisation of Cancer Services

BACKGROUNDnNational Health Service England recently oversaw a whole-scale reconfiguration of cancer services in London, UK, for a number of different cancer pathways. Centralisation of cancer surgery has occurred with prostate cancer (PCa) surgery only being commissioned at a single designated pelvic cancer surgical centre. This process has required surgeons to work in teams providing a hub-and-spoke model of care.nnnOBJECTIVEnTo report the extent to which the initiation of a quality assurance programme (QAP) can improve the quality of PCa surgical care during reorganisation of cancer services in London.nnnDESIGN, SETTING, AND PARTICIPANTSnA pre- and postintervention study was initiated with 732 men undergoing robot-assisted radical PCa surgery over a 3-yr period, 396 men before the introduction of the QAP and 336 afterwards.nnnINTERVENTIONnImage-based surgical planning of cancer surgery and monthly peer review of individual surgeon outcomes incorporating rating and assessment of edited surgical video clips.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnWe observed margin status (positive/negative), complication rate of surgery, 3-mo urinary continence, use of nerve-sparing surgery, and potency at 12 mo after surgery. Multivariable logistic regression modelling was used to compare outcomes before and after initiation of the QAP. Cox regression analysis was used to evaluate the return of potency over time.nnnRESULTS AND LIMITATIONSnDemographics of patients undergoing surgery did not change following the reorganisation of cancer services. Patient-reported 3-mo urinary continence improved following the initiation of the QAP, both in terms of requirement for incontinence pads (57% continent vs 67% continent; odds ratio [OR]: 2.19; 95% confidence interval [CI], 1.08-4.46; p=0.02) and International Consultation on Incontinence Questionnaire score (5.6 vs 4.2; OR: 0.82; 95% CI, 0.70-0.95; p=0.009). Concurrently, use of nerve-sparing surgery increased significantly (OR: 2.99; 95% CI, 2.14-4.20; p<0.001) while margin status remained static. Potency at 12 mo increased significantly from 21% to 61% in those patients undergoing bilateral nerve-sparing surgery (hazard ratio: 3.58; 95% CI, 1.29-9.87; p=0.04). Interaction was noted between surgeon and 3-mo urinary continence. On regression analysis, incontinence scores improved significantly for all but one surgeon who had low incontinence rates at study initiation.nnnCONCLUSIONSnThe implementation of a QAP improved quality of care in terms of consistency of patient selection and outcomes of surgery during a period of major reorganisation of cancer services in London. The QAP framework presented could be adopted by other organisations providing complex surgical care across a large network of referring hospitals.nnnPATIENT SUMMARYnThe introduction of a quality assurance programme improved the quality of prostate cancer care in terms of consistency of patient selection and outcomes of surgery during a period of major reorganisation of cancer services.

Analysis of open and intracorporeal robotic assisted radical cystectomy shows no significant difference in recurrence patterns and oncological outcomes.

OBJECTIVESnTo report and compare early oncological outcomes and cancer recurrence sites among patients undergoing open radical cystectomy (ORC) and robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC).nnnMETHODS AND MATERIALSnA total of 184 patients underwent radical cystectomy for bladder cancer. ORC cases (n = 94) were performed between June 2005 and July 2014 while iRARC cases (n = 90) were performed between June 2011 and July 2014. Primary outcome was recurrence free survival (RFS). Secondary outcomes were sites of local and metastatic recurrence, cancer specific survival (CSS) and overall survival (OS).nnnRESULTSnMedian follow-up for patients without recurrence was 33.8 months (interquartile range [IQR]: 20.5-45.4) for ORC; and 16.1 months (IQR: 11.2-27.0) for iRARC. No significant difference in age, sex, precystectomy T stage, precystectomy grade, or lymph node yield between ORC and iRARC was observed. The ORC cohort included more patients with≥pT2 (64.8% ORC vs. 38.9% iRARC) but fewer pT0 status (8.5% ORC vs.vs. 22.2% iRARC) due to lower preoperative chemotherapy use (22.3% ORC vs. 34.4% iRARC). Positive surgical margin rate was significantly higher in the ORC cohort (19.3% vs. 8.2%; P = 0.042). Kaplan-Meir analysis showed no significant difference in RFS (69.5% ORC vs. 78.8% iRARC), cancer specific survival (80.9% ORC vs. 84.4% iRARC), or OS (73.5% ORC vs.vs. iRARC 83.8%) at 24 months. Cox regression analysis showed RFS, cancer specific survival and OS were not influenced by cystectomy technique. No significant difference between local and metastatic RFS between ORC and iRARC was observed.nnnCONCLUSIONnThis study has found no difference in recurrence patterns or oncological outcomes between ORC and iRARC. Recurrent metastatic sites vary, but are not related to surgical technique.

Recovery of Baseline Erectile Function in Men Following Radical Prostatectomy for High-Risk Prostate Cancer: A Prospective Analysis Using Validated Measures

INTRODUCTIONnRecovery of baseline erectile function (EF) after robotic radical prostatectomy in men with high-risk prostate cancer is under-reported. Published studies have selectively reported on low-risk disease using non-validated and poorly defined thresholds for EF recovery.nnnAIMnTo assess return to baseline EF in men after robotic radical prostatectomy for high-risk prostate cancer.nnnMATERIALSnFive hundred thirty-one men underwent robotic radical prostatectomy for high-risk prostate cancer from February 2010 through July 2014. Pre- and postoperative EF was prospectively assessed using the International Index of Erectile Dysfunction (IIEF-5) questionnaire. Multivariate logistic regression analysis determined the effect of age, preoperative function, comorbidities, body mass index, prostate-specific antigen level, cancer stage or grade, nerve-sparing status, adjuvant therapy, and continence on EF return (defined as postoperative return to baseline EF with or without use of phosphodiesterase type 5 inhibitors). Kaplan-Meier analysis and log-rank test were used to analyze return over time. Mann-Whitney U-test was used to compare IIEF-5 scores.nnnMAIN OUTCOME MEASURESnPre- and postoperative EF was assessed using the IIEF-5 Sexual Health Inventory for Men at 3 months, 6 months, 1 year, 2 years, 3 years, and 4 years postoperatively.nnnRESULTSnOverall, return of EF was seen in 23.5% of patients at 18 months. This was significantly increased in men no older than 60 years (Pxa0= .024), with a preoperative IIEF-5 score of at least 22 (Pxa0= .042), and after undergoing neurovascular bundle preservation (34.9% of patients, P < .001). There was no significant change in IIEF-5 scores from 3 to 36 months in patients who were treated with phosphodiesterase type 5 inhibitors in the non-neurovascular bundle preservation group (Pxa0= .87), although there was significant improvement in those receiving second- or third-line therapies (Pxa0= .042). Other than preoperative hypertension (Pxa0= .03), none of the other comorbidities predicted return of EF.nnnCONCLUSIONnIn this study, 23.5% of men recovered to baseline EF. Of those who underwent bilateral neurovascular bundle preservation robotic radical prostatectomy, 70% recovered baseline EF; however, this accounted for only 9.6% of all patients. Only 4% of men who underwent non-neurovascular bundle preservation had baseline recovery with phosphodiesterase type 5 inhibitors up to 36 months. There was significant improvement after use of second- or third-line therapies, indicating the need for earlier institution of these treatment modalities.

Benefits of robotic cystectomy with intracorporeal diversion for patients with low cardiorespiratory fitness: A prospective cohort study

BACKGROUNDnPatients undergoing radical cystectomy have associated comorbidities resulting in reduced cardiorespiratory fitness. Preoperative cardiopulmonary exercise testing (CPET) measures including anaerobic threshold (AT) can predict major adverse events (MAE) and hospital length of stay (LOS) for patients undergoing open and robotic cystectomy with extracorporeal diversion. Our objective was to determine the relationship between CPET measures and outcome in patients undergoing robotic radical cystectomy and intracorporeal diversion (intracorporeal robotic assisted radical cystectomy [iRARC]).nnnMETHODSnA single institution prospective cohort study in patients undergoing iRARC for muscle invasive and high-grade bladder cancer.nnnINCLUSIONnpatients undergoing standardised CPET before iRARC.nnnEXCLUSIONSnpatients not consenting to data collection. Data on CPET measures (AT, ventilatory equivalent for carbon dioxide [VE/VCO2] at AT, peak oxygen uptake [VO2]), and patient demographics prospectively collected. Outcome measurements included hospital LOS; 30-day MAE and 90-day mortality data, which were prospectively recorded. Descriptive and regression analyses were used to assess whether CPET measures were associated with or predicted outcomes.nnnRESULTSnFrom June 2011 to March 2015, 128 patients underwent radical cystectomy (open cystectomy, n = 17; iRARC, n = 111). A total of 82 patients who underwent iRARC and CPET and consented to participation were included. Median (interquartile range): age = 65 (58-73); body mass index = 27 (23-30); AT = 10.0 (9-11), Peak VO2 = 15.0 (13-18.5), VE/VCO2 (AT) = 33.0 (30-38). 30-day MAE = 14/111 (12.6%): death = 2, multiorgan failure = 2, abscess = 2, gastrointestinal = 2, renal = 6; 90-day mortality = 3/111 (2.7%). AT, peak VO2, and VE/VCO2 (at AT) were not significant predictors of 30-day MAE or LOS. The results are limited by the absence of control group undergoing open surgery.nnnCONCLUSIONSnPoor cardiorespiratory fitness does not predict increased hospital LOS or MAEs in patients undergoing iRARC. Overall, MAE and LOS comparable with other series.

In-depth Critical Analysis of Complications Following Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion

BACKGROUNDnRobot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) is an attractive option to open cystectomy, but the benefit in terms of improved outcomes is not established.nnnOBJECTIVEnTo evaluate the early postoperative morbidity and mortality of patients undergoing iRARC and conduct a critical analysis of complications using standardised reporting criteria as stratified according to urinary diversion.nnnDESIGN, SETTING, AND PARTICIPANTSnA total of 134 patients underwent iRARC for bladder cancer at a single centre between June 2011 and July 2015.nnnINTERVENTIONnRadical cystectomy with iRARC.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnPatient demographics, pathologic data, and 90-d perioperative mortality and complications were recorded. Complications were reported according to the Clavien-Dindo (CD) classification and stratified according to urinary diversion type and either surgical or medical complications. The chi-square test and t test were used for categorical and continuous variables respectively. Multivariable logistic regression was performed on variables with significance in univariate analysis.nnnRESULTS AND LIMITATIONSnThe 90-d all complication rate following ileal conduit and continent diversion was 68% and 82.4%, and major complications were 21.0% and 20.6% respectively. The 90-d mortality was 3% and 2.9% for ileal conduit and continent diversion patients, respectively. On multivariate analysis, the blood transfusion requirement was independently associated with major complications (p=0.002) and all 30-d (p=0.002) and 90-d (p=0.012) major complications. Male patients were associated with 90-d major complications (p=0.015). Critical analysis identified that surgical complications were responsible for 39.4% of all 90-d major complications. The incidence of surgical complications did not decline with increasing number of iRARC cases performed (p=0.742, r=0.31). Limitations of this study include its retrospective nature, limited sample size, and limited multivariate analysis due to the low number of major complications events.nnnCONCLUSIONSnAlthough complications following iRARC are common, most are low grade. A critical analysis identified surgical complications as a cause of major complications. Addressing this issue could have a significant impact on lowering the morbidity associated with iRARC.nnnPATIENT SUMMARYnWe looked at the surgical outcomes in bladder cancer patients treated with minimally invasive robotic surgery. We found that surgical complications account for most major complications and previous surgical experience may be a confounding factor when interpreting results from a different centre even in a randomised trial setting.

Training in Robotic Surgery—an Overview

Purpose of ReviewThere has been a rapid and widespread adoption of the robotic surgical system with a lag in the development of a comprehensive training and credentialing framework. A literature search on robotic surgical training techniques and benchmarks was conducted to provide an evidence-based road map for the development of a robotic surgical skills for the novice robotic surgeon.Recent FindingsA structured training curriculum is suggested incorporating evidence-based training techniques and benchmarks for progress. This usually involves sequential progression from observation, case assisting, acquisition of basic robotic skills in the dry and wet lab setting along with achievement of individual and team-based non-technical skills, modular console training under supervision, and finally independent practice.SummaryRobotic surgical training must be based on demonstration of proficiency and safety in executing basic robotic skills and procedural tasks prior to independent practice.

Port-Site Metastases After Robotic Radical Cystectomy: A Systematic Review and Management Options

Abstract Background: Port‐site metastases (PSMs) are a rare occurrence after robotic surgery. For robot‐assisted radical cystectomy (RARC), isolated cases have been reported but management has not been previously described. We present a case of PSM that occurred after RARC and report the results of our systematic review of previously reported PSMs and describe the treatment options. Search Criteria and Methods: We describe a case of a PSM in a 55‐year‐old man who had undergone intracorporeal RARC. We performed a systematic review of MEDLINE and Embase databases for previously reported PSMs, detailing the stage and grade of the primary tumor, time to presentation of PSM, treatment offered, and outcomes for the identified cases. Results: We identified 4 cases of PSMs after RARC in published studies and also included our case for analysis. All 5 patients had muscle‐invasive bladder cancer at cystectomy (stage ≥ T2) and 3 had local lymph node‐positive disease. Our aggressive treatment of chemotherapy, wide surgical excision of PSM, and radiotherapy provided our patient with a 2‐year disease‐free status. Conclusion: PSMs are a rare event in RARC, with only 4 other cases reported in published studies. The outcomes have not been well reported for these cases. We propose that multimodality treatment consisting of salvage chemotherapy, surgery, and radiotherapy should be considered, although concessions could be needed after consideration of patient factors.

Intracorporeal robotic assisted radical cystectomy together with an enhanced recovery programme improves postoperative outcomes by aggregating marginal gains

To assess the cumulative effect of an enhanced recovery after surgery (ERAS) pathway and minimally invasive robot‐assisted radical cystectomy with intracorporeal urinary diversion (iRARC) in comparison with open radical cystectomy (ORC) on length of hospital stay (LOS) and peri‐operative outcomes.