Robotic-assisted simple prostatectomy: long-term, trifecta- and pentafecta-based analysis of functional outcomes

Background:

Robotic-assisted simple prostatectomy (RASP) proved to be a sound and effective procedure for bladder outlet obstructive symptoms relief. Routinely, the transvesical (Freyer) or transcapsular (Millin) techniques are performed. A novel approach of near-infrared fluorescence imaging (NIFI)-guided urethra-sparing robot-assisted prostatectomy (Madigan) was recently introduced.

Objectives:

The aim of our study was to evaluate the long-term functional outcomes between the Millin, Freyer, and Madigan RASP.

Design:

This is a single-center, retrospective evaluation of a prospectively maintained Institutional Review Board–approved database.

Methods:

Data from patients who have undergone RASP in our center were prospectively collected. Demographics, prostate size, and preoperative flowmetry parameters were assessed. Questionnaires such as International Index of Erectile Function (IIEF), and International Consultation on Incontinence Questionnaire (ICIQ), International prostatic symptoms score (IPSS) with its quality of life (QoL) score, Male Sexual Health Questionnaire (MSHQ), Overactive bladder questionnaire (OABQ) were administered to every patient preoperatively and during follow-up. We tested composite outcomes (trifecta) defined as a combination of postoperative Q-max >15 ml/s, IPSS score < 8, and absence of complications. We also tested a pentafecta which keeps in account the persistence of antegrade ejaculation (MSHQ > 0) and the erectile function maintenance (∆IEEF < 6).

Results:

Median follow-up was 36 months. Millin, Madigan, and Freyer procedures were performed in 37 (51%), 18 (25%), and 17 (24%) cases, respectively. Trifecta was achieved in 43 (60%) patients. Preoperative ICIQ, postoperative IPSS, postoperative OABQ, and QoL were significantly different between groups (all p < 0.02). Pentafecta was achieved by 14 (20%) patients. The pentafecta group showed a statistically significant advantage in terms of postoperative IPSS and MSHQ ( p < 0.01).

Conclusion:

RASP provides an effective and durable relief of obstructive symptoms at long-term follow-up, regardless of the technique, achieving the trifecta in the majority of the patients. The Madigan technique is significantly related to the pentafecta achievement.

Predictors of trainees’ proficiency during the learning curve of robot-assisted radical prostatectomy at high-volume institutions: results from a multicentric series

Introduction

The aim of this series was to evaluate predictors of Proficiency score (PS) achievement on a multicentric series of robot-assisted radical prostatectomies (RARP) performed by trainee surgeons with two different surgical techniques at four tertiary-care centers.

Material and methods

Four institutional datasets were merged and queried for RARPs performed by surgeons during their learning curve (LC) between 2010 and 2020 using two different approaches (Group A, Retzius-sparing RARP, n = 164; Group B, standard anterograde RARP, n = 79). Logistic regression analysis was performed to identify predictors of PS achievement for the overall trainee cohort. For all analyses, a two-sided p <0.05 was considered significant.

Results

Group B showed significantly increased median operative time, positive surgical margins (PSM) status, increased number of nerve-sparing procedures, shorter LC time (each p <0.04). PS, continence status, potency, biochemical recurrence and 1-year trifecta rates were comparable between groups (each p >0.3). On multivariable analysis, time from LC starting ≥12 months (OR = 2.79; 95%IC [1.15-6.76]; p = 0.02) and a nerve-sparing intent (OR = 3.18; 95%IC [1.15-8.77]; p = 0.02) were independent predictors of PS score achievement (Table 3).

Conclusions

Higher PS rates for RARP trainees may be expected after 12 months from LC beginning. Short-term training courses are unlikely to confer proper surgical training, while long-term structured training programs seem to be beneficial on perioperative outcomes.

Effect of vacation on urinary symptoms in health care workers: an Italian multicenter study

BACKGROUND

Aim of our study was to assess the impact of vacation on urinary symptoms in health care workers.

METHODS

Between March 2018 to October 2019 a survey was carried out by enrolling health care system workers in three centers. Demographic and clinical characteristics of health care workers (i.e. age, smoking status, medical history) were collected. Lower urinary tract symptoms (LUTS) and work related quality of life were assessed before and after vacation with validated questionnaires: Overactive Bladder Questionnaire Short Form (OABq-sf), International Prostate Symptom Score (IPSS), Work-related Quality of Life (WRQOL) and SF-36 questionnaires. As well, night shift workers (NSWs), defined as working at least one time a week from 8 pm to 8 am, were compared to traditional workers (TWs).

RESULTS

A total of 236 participants (118 males and 118 females) with a median of 41 (32/49 IQR) years old were included in the survey. Healthcare workers presented after vacation an improvement in LUTS, in work related quality of life and overall health. Overall, 89 (37%) were NSWs and 147 (62%) subjects were TWs. NSWs reported a significant higher median OABq Total Score and IPSS than TWs: respectively, 27 (IQR 23-34) vs. 20 (IQR 19-24) P=0.01, 2 (0/6) vs. 0 (0/2) (P<0.01). No significative differences were found for WRQOL and SF36, respectively 66 (IQR 59/77) vs. 67 (IQR 61/82) (P<0.29) and 98 (97/101) vs. 98 (97/100) (P<0.79).

CONCLUSIONS

NSWs present worst urinary symptoms when compared to TWs. Vacation has a beneficial effect, particularly in NSWs, on urinary symptoms and work-related quality of life.

Clinical cure vs a novel trifecta system for evaluating long-term outcomes of minimally-invasive partial or total adrenalectomy for unilateral primary aldosteronism: results of a multicentric series

Introduction

Several predictive scores to evaluate outcomes of adrenal surgery for unilateral primary aldosteronism (UPA), have been conceived. We compared a novel trifecta that summarizes outcomes of adrenal surgery for UPA with the clinical cure proposed by Vorselaars.

Material and methods

Between March 2011 and January 2022, a multi-institutional dataset was queried for UPA. Baseline, perioperative and functional data were collected. Clinical and biochemical complete and partial success rates according to Primary Aldosteronism Surgical Outcome (PASO) criteria were assessed for the overall cohort. Clinical cure was defined either as normotension without antihypertensive medications or normotension with lower or equal use of antihypertensive medications. Trifecta was defined as the coexistence of ≥50% antihypertensive therapeutic intensity score (TIS) reduction (ΔTIS), no electrolyte impairment at 3-months and no Clavien-Dindo (2-5) complications. Cox regression analyses were used to identify predictors of long-term clinical and biochemical success. For all analyses, a two-sided p <0.05 was considered significant.

Results

Baseline, perioperative and functional outcomes were analyzed. Out of 90 patients, at a median follow-up of 42 months (IQR 27-54) a complete and partial clinical success was observed in 60% and 17.7% of cases while a complete and partial biochemical success was achieved in 83.3% and 12.3% of cases, respectively. Overall trifecta and clinical cure rates were 21.1% and 58.9%, respectively. On multivariable Cox regression analysis, trifecta achievement (HR 2.87; 95% CI 1.45-5.58; p = 0.02) was the only independent predictor of complete clinical success at long-term follow-up.

Conclusions

Despite its complex estimation and more restrictive criteria, trifecta but not clinical cure allows to independently predict composite PASO endpoints on the long run.

On-Clamp vs. Off-Clamp Robot-Assisted Partial Nephrectomy for cT2 Renal Tumors: Retrospective Propensity-Score-Matched Multicenter Outcome Analysis

We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13−4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27−0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.

Redo Robotic Partial Nephrectomy for Recurrent Renal Tumors: A Multi-Institutional Analysis

INTRODUCTION

As the experience with robot assisted partial nephrectomy (RAPN) grows, the indications have expanded to incorporate previously operated ipsilateral kidneys with recurrent renal masses. We sought to analyze the outcomes of redo RAPN in patients with a recurrent renal mass.

METHODS

Using a multi-institutional series, the data of 72 patients who underwent RAPN for a recurrent renal mass between 2010 and 2020 were retrospectively analyzed. Patients with familial renal cell carcinoma and multiple renal tumors were excluded. Major complication defined by Clavien grade ≥3. The median follow-up was 28.5 months. Baseline demographics, clinical and tumor characteristics, perioperative and postoperative outcomes are reported.

RESULTS

Our cohort consisted of a combination of previous thermal ablation (19.6%), laparoscopic (19.6%), open (26.1%), and robotic (34.8%) partial nephrectomy. The median RENAL score was 8. Twenty percent had hilar tumors and 9.7% had a solitary kidney. RAPN was completed in all cases. Two cases (2.8%) were converted to open surgery. None of the cases were converted to radical nephrectomy intraoperatively. One patient underwent radical nephrectomy postoperatively due to bleeding. Transfusion rate was 5.9% and major complication rate was 8.3%. Median length of stay was 3 days. eGFR preservation was 78.7% at discharge and 90.8% at one-year follow-up. Positive surgical margin rate was 8.3%. Overall, distant recurrence was seen in 11 patients (15.3%), however, only one patient had local progression (1.4%).

CONCLUSION

In experienced hands, RAPN is an effective approach to treat select cases of locally recurrent renal masses with promising perioperative and functional outcomes. Patients should be carefully monitored for distant recurrence.

Volatilome Analysis in Prostate Cancer by Electronic Nose: A Pilot Monocentric Study

Urine analysis via an electronic nose provides volatile organic compounds easily usable in the diagnosis of urological diseases. Although challenging and highly expensive for health systems worldwide, no useful markers are available in clinical practice that aim to anticipate prostate cancer (PCa) diagnosis in the early stages in the context of wide population screening. Some previous works suggested that dogs trained to smell urine could recognize several types of cancers with various success rates. We hypothesized that urinary volatilome profiling may distinguish PCa patients from healthy controls. In this study, 272 individuals, 133 patients, and 139 healthy controls participated. Urine samples were collected, stabilized at 37 °C, and analyzed using a commercially available electronic nose (Cyranose C320). Statistical analysis of the sensor responses was performed off-line using principal component (PCA) analyses, discriminant analysis (CDA), and ROC curves. Principal components best discriminating groups were identified with univariable ANOVA analysis. groups were identified with univariable ANOVA analysis. Here, 110/133 and 123/139 cases were correctly identified in the PCa and healthy control cohorts, respectively (sensitivity 82.7%, specificity 88.5%; positive predictive value 87.3%, negative predictive value 84.2%). The Cross Validated Accuracy (CVA 85.3%, p < 0.001) was calculated. Using ROC analysis, the area under the curve was 0.9. Urine volatilome profiling via an electronic nose seems a promising non-invasive diagnostic tool.

Robotic Repair of Ureteroenteric Stricture Following Radical Cystectomy: A Multi-Institutional Experience

OBJECTIVE

To examine the safety, feasibility and durability of robotic reimplantation of ureteroenteric stricture after radical cystectomy.

MATERIALS AND METHODS

A retrospective multi-institutional review was performed for all patients undergoing robotic repair of ureteroenteric stricture from January 2010 to January 2019. Functional outcomes and complications were followed and data were analyzed with SPSS statistical software.

RESULTS

A total of 46 patients and 58 renal units were identified, of which 15 had right sided, 19 left sided and 12 patients had bilateral strictures. Presentation of stricture was asymptomatic in 14 (30.4%) patients. Symptomatic presentations included infection in 22 (47.8%), worsening renal function in 11 (23.9%) and pain in 3 (6.5%) patients. Median time from cystectomy to diagnosis of stricture was 5 months (1-40). Median stricture length was 1.5 cm (range 0.5-10). All strictures were of benign etiology except for 4 (6.9%), which were due to malignancy. Overall, 49 (84.5%) ureters underwent primary re-implantation, while 9 (15.5%) required Boari-like advancement flaps prior to re-implantation. Median operative time was 190 min (range 45-540) with median estimated blood loss of 50 mL (range 25-2000) and median length of stay of 2 days (range 1-33, IQR 2-4). Seven (15.2%) patients experienced complications; 3 (6.5%) were low grade and 4 (8.7%) high grade. With median follow up of 18 months (range 1-51) the stricture recurrence rate was 8.6%.

CONCLUSION

Robotic reimplantation of ureteroenteric strictures following radical cystectomy is safe and feasible in experienced centers with high success rates.

Surgical Quality, Antihypertensive Therapy, and Electrolyte Balance: A Novel Trifecta to Assess Long-Term Outcomes of Adrenal Surgery for Unilateral Primary Aldosteronism

BACKGROUND

To propose a trifecta that summarizes endpoints and predicts their maintenance after adrenalectomy (n = 90) for unilateral primary aldosteronism (UPA).

METHODS

Trifecta was defined as coexistence of: ≥50% antihypertensive therapeutic intensity score reduction (∆TIS), no hypokalemia at 3 months, and no Clavien grade 2-5. Logistic regression was used to identify predictors of trifecta. Probability of clinical, biochemical, and simultaneous success according to trifecta were assessed by Kaplan-Meier. Cox regression was used to identify predictors of long-term clinical, biochemical, and simultaneous success. For all analyses, a two-sided p < 0.05 was considered significant.

RESULTS

Simultaneous success rate was 50%. On multivariable analysis, TIS was an independent predictor of trifecta achievement (HR 3.28; 95% CI 1.07-10.9; p = 0.03). At Kaplan-Meier, trifecta predicted higher success for all endpoints (each p < 0.03). On multivariable Cox analysis, adenoma size (AS) ≥6 cm and trifecta were independent predictors of biochemical (AS: HR 2.87; 95% CI 1.53-5.36; trifecta: HR 2.1; 95% CI 1.13-3.90; each p < 0.02) and simultaneous success (AS: HR 3.81; 95% CI 1.68-8.65; trifecta: HR 4.29; 95% CI 2.08-8.86; each p < 0.01), while trifecta was an independent predictor of complete clinical success (HR 2.84; 95% CI 1.45-5.58; p < 0.01).

CONCLUSIONS

Trifecta and AS are independent predictors of either long-term complete clinical, biochemical, or combined success after adrenalectomy for UPA.