Robot-Assisted Surgery in Urology: The Show Must Go On

Robot-assisted radical cystectomy with intracorporeal reconstruction of urinary diversion by mechanical stapler: prospective evaluation of early and late complications

Introduction

Radical cystectomy with pelvic lymph node dissection is the gold standard treatment for non-metastatic muscle-invasive bladder cancer and high-risk non-muscle-invasive bladder cancer. For years, the traditional open surgery approach was the only viable option. The widespread of robotic surgery led to its employment also in radical cystectomy to reduce complication rates and improve functional outcomes. Regardless of the type of approach, radical cystectomy is a procedure with high morbidity and not negligible mortality. Data available in the literature show how the use of staplers can offer valid functional outcomes, with an acceptable rate of complications shortening the operative time. The aim of our study was to describe the perioperative outcomes and complications associated with robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) using a mechanical stapler.

Material and methods

From January 2015 to May 2021, we enrolled patients who underwent RARC with pelvic node dissection and stapled ICUD (ileal conduit or ileal Y-shaped neobladder according to the Perugia ileal neobladder) in our high-volume center. Demographic features, perioperative outcomes and early (≤30 days) and late (>90 days) post-operative complications according to the Clavien-Dindo classification, were recorded for each patient. We also analyzed the potential linear correlation between demographic, pre-operative as well as operative features and the risk of post-operative complications.

Results

Overall, 112 patients who underwent RARC with ICUD were included with a minimum follow-up of 12 months. Intracorporeal Perugia ileal neobladder was performed in 74.1% of cases while ileal conduit was performed in 25.9%. The mean operative time, estimated intraoperative blood loss, and LOS were 289.1 ± 59.7 min, 390.6 ± 186.2 ml, and 17.5 ± 9.8 days, respectively. Early minor and major complications accounted for 26.7% and 10.8%, respectively. Overall late complications were 40.2%. The late most common complications were hydronephrosis (11.6%) and urinary tract infections (20.5%). Stone reservoir formation occurred in 2.7% of patients. Major complications occurred in 5.4%. In the sub-analysis, the mean operative time and the estimated blood loss improved significantly from the first 56 procedures to the last ones.

Conclusion

RARC with ICUD performed by mechanical stapler is a safe and effective technique. Stapled Y-shaped neobladder did not increase the complication rate.

Functional, oncological outcomes and safety of laparoscopic partial nephrectomy versus open partial nephrectomy in localized renal cell carcinoma patients with high anatomical complexity

PURPOSE

Partial nephrectomy (PN) is the main treatment strategy for localized renal cell carcinoma (RCC). However, for RCC with high anatomical complexity, PN remains a challenge for urologists. Therefore, this study aimed to evaluate the functional oncological outcomes and safety of laparoscopic partial nephrectomy (LPN) versus open partial nephrectomy (OPN) in localized RCC patients with highly anatomical complexity (R.E.N.A.L. score ≥ 10).

PATIENTS AND METHODS

We retrospectively studied 575 patients who underwent PN at our center between January 2007 and December 2017. After propensity score-matching (PSM), 137 patients treated with LPN and 54 patients treated with OPN were balanced into 97 and 44 pairs. Patient demographics, and extensive perioperative and prognostic data were recorded and compared.

RESULTS

In the matched group, the OPN group had significantly less eGFR loss than the LPN group (2.57 ml/min/1.73 m² vs. 31.59 ml/min/1.73 m², P < 0.001). The recurrence-free survival (P = 0.287), overall survival (P = 0.296), cancer-specific survival (P = 0.664), and cardiocerebrovascular disease-specific survival (P = 0.341) were equivalent between groups. The rates of minor (P = 0.621) and major (P = 0.647) complications were also similar between groups.

CONCLUSIONS

This PSM cohort study showed that OPN resulted in better renal function preservation than LPN in localized RCC patients with high anatomical complexity, and had comparable oncological and safety outcomes after long-term follow-up. These findings may help improve clinical decision-making for localized RCC patients with high anatomical complexity.

Combined Open Prostatectomy and Kidney Surgery: Feasibility and 12-Month Outcome

Purpose

There are only a few case reports and case series that investigated combined laparoscopic or robotic surgery for simultaneous prostate and kidney cancer. In this study, we want to close a gap in existing research to assess the feasibility and oncological outcome of combined open prostatectomy and kidney surgery.

Methods

We retrospectively analyzed patients who underwent a combined open prostatectomy and either a partial or complete nephrectomy from 2013 to 2020. Descriptive statistics were used to assess perioperative parameters and the 12-month functional and oncological outcomes after combined surgery.

Results

We identified 10 patients undergoing combined open surgery. Partial nephrectomy was performed in 4, radical nephrectomy in 6 patients. For prostate cancer, histopathological analysis showed a tumor stage ≥ pT2c in all 10 patients. For renal tumors, histopathological analysis showed clear cell renal cell carcinoma in 8 patients and oncocytoma in 2 patients. Operating time was 177 ± 36 minutes. Two perioperative complications (Clavien 2a and 3) were observed. Three months postoperatively, the International Index of Erectile Function (IIEF-5) score was 5.6 ± 5.9, the ICIQ-SF score was 7.3 ± 5.6 and were using 1.9 ± 2.2 pads per day. This improved after 12 months postoperatively, as patients had an IIEF-5 score of 6.33 ± 6.5, an ICIQ-SF score of 4.4 ± 5.7 and were using pads 0.9 ± 1.7 per day.

Conclusion

In this study, we showed that open surgery is a safe and valid approach for combined prostatectomy and renal surgery with acceptable complications and oncological outcomes. The combined open approach could be a good alternative to combined laparoscopic/robotic surgery in this field, especially to treat patients with advanced renal tumors or previous abdominal surgery or radiation.

Concomitant robot-assisted laparoscopic surgeries for upper and lower urinary tract malignancies: a comprehensive literature review

Worldwide, we have witnessed an expansion of robot-assisted laparoscopic surgery (RALS) and thanks to the global adoption of high-resolution diagnostic imaging technologies, an increased incidence of newly diagnosed prostatic, renal and bladder cancers has been recorded with concurrent second primary urological cancer diagnoses increasing by 1.5%. Diverse authors have reported their findings concerning synchronous multi-visceral malignances robotic treatment within the scientific literature. The aim of this study is to comprehensively review all reported articles describing concurrent upper and lower RALS using a singular robotic port scheme within the same intervention for renal malignances and concomitant prostatic or bladder cancers. To the best of our knowledge and vigorous literature search, this is the first study that comprehensively evaluates and reports all combined upper and lower urinary tract surgeries published so far. In carefully selected patients, thanks to multidisciplinary preoperative assessment and surgical planning a combined robotic approach can reduce the morbidity, complications, hospital admissions and the overall length of hospitalization.

Three-dimensional (3D) reconstruction and navigation in robotic-assisted partial nephrectomy (RAPN) for renal masses in the solitary kidney: A comparative study

BACKGROUND

Numerous efforts were made to improve renal function and oncologic outcomes in surgery for patients with kidney cancer. We explored new robotic methods in solitary kidneys.

MATERIALS AND METHODS

We prospectively registered and included 16 patients in the 3D-robot-assisted partial nephrectomy (RAPN) group with a solitary kidney (anatomic or functional), and retrospectively identified 25 patients with a solitary kidney who received RAPN also operated by us for comparison.

RESULTS

The rates of global clamping reduced in the 3D-RAPN group (37.5% vs 76%)while selective rates were higher (56.2% vs 20%) (p = 0.028). The mean percentages of Scr increase (+20.2% vs +30.2%, p = 0.045) and eGFR reduction (-16.8% vs -27.1%) as well as rate of opening collecting systems (31.3% vs 72%, p = 0.010) were lower in 3D-RAPN group.

CONCLUSIONS

3D-RAPN less impaired the renal function of patients with a solitary kidney and showed superiority or non-inferiority in other evaluation indexes compared to conventional RAPN.

Surgical Management of Giant L2 Adrenal Neuroblastoma in Adult Male

Neuroblastoma is an embryonal malignancy that arises from neural crest cells. Adult adrenal neuroblastoma is a rare disease, and less than 100 cases were reported in the literature. Adult neuroblastoma commonly presents with abdominal (retroperitoneal) lump and pain. A 35-year-old male patient presented with a giant (20 cm × 17 cm × 12 cm) nonfunctional left adrenal mass. He underwent en-bloc surgical excision of the left adrenal gland along with the left kidney. Histopathological examination revealed adrenal neuroblastoma (stage 2B, L2). We present here the surgical management of the rare adult adrenal neuroblastoma.

Combined Robotic Surgery for Double Renal Masses and Prostate Cancer: Myth or Reality?

With the widespread use of imaging modalities performed for the staging of prostate cancer, the incidental detection of synchronous tumors is increasing in frequency. Robotic surgery represents a technical evolution in the treatment of solid tumors of the urinary tract, and it can be a valid option in the case of multi-organ involvement. We reported a case of synchronous prostate cancer and bifocal renal carcinoma in a 66-year-old male. We performed the first case of a combined upper- and lower-tract robotic surgery for a double-left-partial nephrectomy associated with radical prostatectomy by the transperitoneal approach. A comprehensive literature review in this field has also been carried out. Total operative time was 265 min. Renal hypotension time was 25 min. Blood loss was 250 mL. The patient had an uneventful postoperative course. No recurrence occurred after 12 months. In the literature, 10 cases of robotic, radical, or partial nephrectomy and simultaneous radical prostatectomy have been described. Robotic surgery provides less invasiveness than open surgery with comparable oncological efficacy, overcoming the limitations of the traditional laparoscopy. During robotic combined surgery for synchronous tumors, the planning of the trocars' positioning is crucial to obtain good surgical results, reducing the abdominal trauma, the convalescence, and the length of hospitalization with a consequent cost reduction. Rare complications can be related to prolonged pneumoperitoneum. Simultaneous robotic prostatectomy and partial nephrectomy appears to be a safe and feasible surgical option in patients with synchronous prostate cancer and renal cell carcinoma.

Simultaneous totally robotic rectal resection and partial nephrectomy: case report and review of literature

Introduction

The incidence of synchronous RCC and colorectal cancer is heterogeneous ranging from 0.03 to 4.85%. Instead, only one case of huge colon carcinoma and renal angiomyolipoma was reported. The treatment of synchronous kidney and colorectal neoplasm is, preferably, synchronous resection. Currently, laparoscopic approach has shown to be feasible and safe, and it has become the gold standard of synchronous resection due to advantages of minimally invasive surgery. We presented a case synchronous renal neoplasm and colorectal cancer undergone simultaneous totally robotic renal enucleation and rectal resection with primary intracorporeal anastomosis. As our knowledge, this is the first case in literature of simultaneous robotic surgery for renal and colorectal tumor.

Case presentation

A 53-year-old woman was affected by recto-sigmoid junction cancer and a solid 5 cm left renal mass. We performed a simultaneous robotic low anterior rectal resection and renal enucleation. Total operative time was 260 min with robotic time of 220 min; estimated blood loss was 150 ml; time to flatus was 72 h, and oral diet was administered 4 days after surgery. The patient was discharged on the eighth post-operative day without peri- and post-operative complication. The definitive histological examination showed a neuroendocrine tumor pT2N1 G2, with negative circumferential and distal resection margins. Renal tumor was angiomyolipoma. At 23 months follow-up, the patient is recurrence free.

Discussion and conclusion

As our knowledge, we described the first case in literature of simultaneous robotic anterior rectal resection and partial nephrectomy for treatment of colorectal tumor and renal mass. Robotic rectal resection with intracorporeal anastomosis surgery seems to be feasible and safe even when it is associated with simultaneous partial nephrectomy. Many features of robotic technology could be useful in combined surgery. This strategy is recommended only when patients’ medical conditions allow for longer anesthesia exposure. The advantages are to avoid a delay treatment of second tumor, to reduce the time to start the post-operative adjuvant chemotherapy, to avoid a second anesthetic procedure, and to reduce the patient discomfort. However, further studies are needed to evaluate robotic approach as standard surgical strategy for simultaneous treatment of colorectal and renal neoplasm.