Youssef Ahmed

Early Oncologic Failure after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

Purpose: We sought to investigate the prevalence and variables associated with early oncologic failure. Materials and Methods: We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot‐assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot‐assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan‐Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival. Results: A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38–5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00–6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21–3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001). Conclusions: The incidence of early oncologic failure following robot‐assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot‐assisted radical cystectomy.

Natural History, Predictors and Management of Ureteroenteric Strictures after Robot Assisted Radical Cystectomy

Purpose: Ureteroenteric strictures represent the most common complication requiring reoperation after radical cystectomy. We investigated the prevalence, outcomes, predictors and management of ureteroenteric strictures. Materials and Methods: We retrospectively reviewed our quality assurance, robot assisted radical cystectomy database to identify patients in whom ureteroenteric strictures developed. Data were reviewed for demographics, perioperative outcomes and ureteroenteric stricture characteristics. The Kaplan‐Meier method was used to calculate time to ureteroenteric stricture and multivariable stepwise regression was done to evaluate predictors of ureteroenteric strictures. Results: Ureteroenteric strictures developed in 12%, 16% and 19% of 51 patients (13%) at 1, 3 and 5 years after robot assisted radical cystectomy, respectively. All patients were initially treated endoscopically or percutaneously, including 57% treated only endoscopically or percutaneously and 43% who required surgery, which was open repair in 6 and robot assisted repair in 16. At a median followup of 23 months 33 patients (65%) were free of disease, including 13 after endoscopic or percutaneous treatment, 15 after robot assisted repair and 5 after open revision. Open and robot assisted revisions showed comparable perioperative outcomes. On multivariable analysis the predictors of ureteroenteric anastomotic strictures were body mass index (OR 1.07, 95% CI 1.01–1.13, p = 0.02), intracorporeal urinary diversion (OR 3.28, 95% CI 1.41–7.61, p = 0.006), length of the right resected ureter (OR 0.66, 95% CI 0.50–0.88, p = 0.004), estimated glomerular filtration rate 30 days after assisted radical cystectomy (OR 0.85, 95% CI 0.74–0.98, p = 0.03), urinary tract infection (OR 2.68, 95% CI 1.31–5.49, p = 0.007) and leakage (OR 3.85, 95% CI 1.05–14.1, p = 0.04). Male gender (OR 0.19, 95% CI 0.04–0.96, p = 0.04) and higher body mass index (OR 0.85, 95% CI 0.72–0.996, p = 0.05) were associated with lower odds of successful endoscopic management. Conclusions: Multiple modifiable factors were associated with ureteroenteric anastomotic strictures following robot assisted radical cystectomy. Surgical revision can provide a definitive management with comparable outcomes for open and robotic repairs.

Outcomes of Intracorporeal Urinary Diversion after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

Purpose: This study aimed to provide an update and compare perioperative outcomes and complications of intracorporeal and extracorporeal urinary diversion following robot‐assisted radical cystectomy using data from the multi‐institutional, prospectively maintained International Robotic Cystectomy Consortium database. Materials and Methods: We retrospectively reviewed the records of 2,125 patients from a total of 26 institutions. Intracorporeal urinary diversion was compared with extracorporeal urinary diversion. Multivariate logistic regression models using stepwise variable selection were fit to evaluate preoperative, operative and postoperative predictors of intracorporeal urinary diversion, operative time, high grade complications and 90‐day hospital readmissions after robot‐assisted radical cystectomy. Results: In our cohort 1,094 patients (51%) underwent intracorporeal urinary diversion. These patients demonstrated shorter operative time (357 vs 400 minutes), less blood loss (300 vs 350 ml) and fewer blood transfusions (4% vs 19%, all p <0.001). They experienced more high grade complications (13% vs 10%, p = 0.02). Intracorporeal urinary diversion use increased from 9% of all urinary diversions in 2005 to 97% in 2015. Complications after this procedure decreased significantly with time (p <0.001). On multivariable analysis higher annual cystectomy volume (OR 1.02, 95% CI 1.01–1.03, p <0.002), year of robot‐assisted radical cystectomy (2013–2016 OR 68, 95% CI 44–105, p <0.001) and American Society of Anesthesiologists® score less than 3 (OR 1.75, 95% CI 1.38–2.22, p <0.001) were associated with undergoing intracorporeal urinary diversion. The procedure was associated with a shorter operative time of 27 minutes (p = 0.001). Conclusions: The use of intracorporeal urinary diversion has increased in the last decade. A higher annual institutional volume of robot‐assisted radical cystectomy was associated with intracorporeal urinary diversion as well as with shorter operative time. Although intracorporeal urinary diversion was associated with higher grade complications than extracorporeal urinary diversion, they decreased with time.

Robot‐assisted approach to ‘W’‐configuration urinary diversion: a step‐by‐step technique

To describe a detailed step‐by‐step approach of our technique for robot‐assisted intracorporeal ‘W’‐configuration orthotopic ileal neobladder.

Natural History and Predictors of Parastomal Hernia after Robot-Assisted Radical Cystectomy and Ileal Conduit Urinary Diversion

Purpose We investigated the prevalence of and variables associated with parastomal hernia and its outcomes after robot‐assisted radical cystectomy and ileal conduit creation for bladder cancer. Materials and Methods We retrospectively reviewed the records of patients who underwent robot‐assisted radical cystectomy at our institution. Parastomal hernia was defined as the protrusion of abdominal contents through the stomal defect in the abdominal wall on cross‐sectional imaging. Parastomal hernia was further described in terms of patient and hernia characteristics, symptoms, management and outcomes. The Kaplan‐Meier method was used to determine time to parastomal hernia and time to surgery. Multivariate stepwise logistic regression was done to evaluate variables associated with parastomal hernia. Results A total of 383 patients underwent robot‐assisted radical cystectomy and ileal conduit creation. Of the patients 75 (20%) had parastomal hernia, which was symptomatic in 23 (31%), and 11 (15%) underwent treatment. Median time to parastomal hernia was 13 months (IQR 9–22). Parastomal hernia developed in 9%, 23% and 32% of cases at 1, 2 and 3 years, respectively. Patients with parastomal hernia had a significantly higher body mass index (30 vs 28 kg/m2, p = 0.02), longer overall operative time (357 vs 340 minutes, p = 0.01) and greater blood loss (325 vs 250 ml, p = 0.04). On multivariate analysis operative time (OR 1.25, 95% CI 1.21–3.90, p <0.001), a fascial defect 30 mm or greater (OR 5.23, 95% CI 2.32–11.8, p <0.001) and a lower postoperative estimated glomerular filtration rate (OR 2.17, 95% CI 1.21–3.90, p = 0.01) were significantly associated with parastomal hernia. Conclusions Symptoms develop in approximately a third of patients with parastomal hernia and 15% will require surgery. The risk of parastomal hernia plateaued after postoperative year 3. Longer operative time, a larger fascial defect and lower postoperative kidney function were associated with parastomal hernia.

Development of a patient and institutional-based model for estimation of operative times for robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium

To design a methodology to predict operative times for robot‐assisted radical cystectomy (RARC) based on variation in institutional, patient, and disease characteristics to help in operating room scheduling and quality control.

MP51-05 DOES TRAINEE PERFORMANCE IMPACT SURGEON'S STRESS DURING ROBOT-ASSISTED SURGERY?

INTRODUCTION AND OBJECTIVES: Stress increases mental workload leading to reduction in surgical performance and subsequently risking patient safety. Console surgeon and their teams often experience mental stress, yet there is little research about objective measurement of stress levels in the operating room during Robot-assisted Surgery (RAS). In the study, brain activity data are used to differentiate between causes of mental stress of mentor surgeon and the impact of trainee performance during RAS. METHODS: EEG data from surgical mentor while observing 87 Urethro-Vesical Anastomoses (UVA) and 74 Pelvic Lymph Node Dissections (PLND) performed by 3 trainees, as well as performing 26 UVA and 26 PLND is recorded. Level and type of mental stress were determined using the power spectral density, during different frequencies, of signals from 20 channel EEG. Performance scores were used to identify the relationship between performance and stress. Stress caused by worry about ability of safe completion were estimated by using the brain activity during upper alpha (11-12 Hz), sensorimotor rhythm (SMR, 12-15 Hz), and low beta (19-22 Hz) bands in the “Cz” channel (area in motor cortex). The activity at the upper beta and gamma was used to estimate stress level and anxiety and fear caused by risk prediction. RESULTS: Mentor’s brain faces two main types of stresses during RAS. While observing low quality performance by trainee surgeons, the cause of mentor’s mental stress is mostly worries about lack of proficiency of trainee surgeon (Type 1). However, stress of mentor while performing surgery or observing a high quality performance by trainee surgeon, is mostly the result of situation awareness and risk prediction on the operative field (Type 2). These two types of stress activate different areas of the brain in specific frequencies. CONCLUSIONS: EEG can be used to separate different types of stress experienced during performing and mentoring robot-assisted surgery. A deeper understanding of the difference and effect of these stresses and their outcomes can lead to targeted intervention and quality improvement. Source of Funding: Roswell Park Alliance Foundation.

PD41-09 COMPARING INTRACORPOREAL URINARY DIVERSION AFTER ROBOT-ASSISTED RADICAL CYSTECTOMY: RESULTS FROM THE INTERNATIONAL ROBOTIC CYSTECTOMY CONSORTIUM; A MATCHED ANALYSIS

NAC in LR patients was significantly associated with greater odds of finding pT1 disease at RC (OR 2.62; p<0.001) as well as pT0 status (OR 2.82; p<0.001); however, receipt of NAC in LR patients was not associated with a significant difference in 5-year cancer-specific survival (65% vs 68%; p1⁄40.31). CONCLUSIONS: Our results validate the proposed risk groups for patients with MIBC and support the use of NAC for HR patients. Moreover, we noted that, while NAC in LR patients was associated with a higher likelihood of favorable pathologic outcomes, only aminority (4.7%) of LR patients treated with up front RC were upstaged but unable to receive adjuvant chemotherapy due to postoperative complications, and receipt of NAC in LR patients was not associated with improved survival.

Female Robot Assisted Radical Cystectomy - Anterior Exenteration

Robot-assisted radical cystectomy (RARC) has evolved as a viable alternative option to the standard open radical cystectomy as a treatment option for muscle-invasive bladder cancer, and refractory non-muscle invasive disease. The objective of this chapter is to summarize the preoperative preparation, key technical steps for RARC performed in female patients using our “Technique of Spaces”, and to summarize the postoperative outcomes.

Robot-Assisted Intracorporeal Ileal Conduit Urinary Diversion

Deciding the most appropriate method for urinary diversion is usually individually tailored according to the patient and disease characteristics, and the availability of specially trained staff to assist with perioperative management and patient education. Ileal conduit remains the most popular diversion method in United States. Robot-assisted radical cystectomy has been associated with equivalent oncological efficacy and safety to open radical cystectomy, while providing superior perioperative outcomes and enhanced recovery. In this chapter, we sought to describe a step-by-step approach to intracorporeal ileal conduit using the “Marionette” technique, and to summarize the perioperative preparation and outcomes.