A Comprehensive Overview of Intraoperative Complications during Retzius-Sparing Robot-Assisted Radical Prostatectomy: Single Series from High-Volume Center

BACKGROUND

Intraoperative complications (ICs) are invariably underreported in urological surgery despite the recent endorsement of new classification systems. We aimed to provide a detailed overview of ICs during Retzius-sparing robot-assisted radical prostatectomy (RS-RARP).

METHODS

We prospectively collected data from 1891 patients who underwent RS-RARP at a single high-volume European center from January 2010 to December 2022. ICs were collected based on surgery reports and categorized according to the Intraoperative Adverse Incident Classification (EAUiaiC). The quality criteria for accurate and comprehensive reporting of intraoperative adverse events proposed by the Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration Project were fulfilled. To better classify the role of the RS-RARP approach, ICs were classified into anesthesiologic and surgical ICs. Surgical ICs were further divided according to the timing of the complication in RARP-related ICs and ePNLD-related ICs.

RESULTS

Overall, 40 ICs were reported in 40 patients (2.1%). Ten out of thirteen ICARUS criteria were satisfied. According to EAUiaiC grading of ICs, 27 (67.5%), 7 (17.5%), 2 (5%), 2 (5%), and 2 (5%) patients experienced Grade 1, 2, 3, 4A, and 4B, respectively. When we classified the ICs, two cases (5%) were classified as anesthesiologic ICs. Among the 38 surgical ICs, 16 (42%) were ePNLD-related, and 22 (58%) were RARP-related. ICs led to seven (0.37%) post-operative sequelae (four non-permanent and three permanent). Patients who suffered ICs were significantly older (67 years vs. 65 years, p = 0.02) and had a higher median BMI (27.0 vs. 26.1, p = 0.01), but did not differ in terms of comorbidities or tumor characteristics (all p values ≥ 0.05).

CONCLUSIONS

Intraoperative complications during RS-RARP are relatively infrequent, but should not be underestimated. Patients suffering from ICs are older, have a higher body mass index, a higher rate of intraoperative blood transfusion, and a longer length of stay.

Does Retzius-Sparing robot-assisted radical prostatectomy guarantee optimal urinary continence recovery across all ages?

The association between age at surgery and urinary continence (UC) recovery after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) is not well established. We addressed this knowledge gap, relying on a large series of 1,417 patients treated with RS-RARP at a high-volume centre between 2010 and 2021. Multivariable logistic models, as well as LOESS plot functions were performed. The probability of immediate, as well as 12-month UC-recovery progressively declined with increasing age at surgery, and per 5-years age at surgery increase reached the independent predictor status for both immediate and 12-month UC-recovery. These findings may significantly improve the quality of patient counseling regarding RS-RARP.

The Oncological and Functional Prognostic Value of Unconventional Histology of Prostate Cancer in Localized Disease Treated with Robotic Radical Prostatectomy: An International Multicenter 5-Year Cohort Study

BACKGROUND AND OBJECTIVE

The impact of prostate cancer of unconventional histology (UH) on oncological and functional outcomes after robot-assisted radical prostatectomy (RARP) and adjuvant radiotherapy (aRT) receipt is unclear. We compared the impact of cribriform pattern (CP), ductal adenocarcinoma (DAC), and intraductal carcinoma (IDC) in comparison to pure adenocarcinoma (AC) on short- to mid-term oncological and functional results and receipt of aRT after RARP.

METHODS

We retrospectively collected data for a large international cohort of men with localized prostate cancer treated with RARP between 2016 and 2020. The primary outcomes were biochemical recurrence (BCR)-free survival, erectile and continence function. aRT receipt was a secondary outcome. Kaplan-Meier survival and Cox regression analyses were performed.

KEY FINDINGS AND LIMITATIONS

A total of 3935 patients were included. At median follow-up of 2.8 yr, the rates for BCR incidence (AC 10.7% vs IDC 17%; p < 0.001) and aRT receipt (AC 4.5% vs DAC 6.3% [p = 0.003] vs IDC 11.2% [p < 0.001]) were higher with UH. The 5-yr BCR-free survival rate was significantly poorer for UH groups, with hazard ratios of 1.67 (95% confidence interval [CI] 1.16-2.40; p = 0.005) for DAC, 5.22 (95% CI 3.41-8.01; p < 0.001) for IDC, and 3.45 (95% CI 2.29-5.20; p < 0.001) for CP in comparison to AC. Logistic regression analysis revealed that the presence of UH doubled the risk of new-onset erectile dysfunction at 1 yr, in comparison to AC (grade group 1-3), with hazard ratios of 2.13 (p < 0.001) for DAC, 2.14 (p < 0.001) for IDC, and 2.01 (p = 0.011) for CP. Moreover, CP, but not IDC or DAC, was associated with a significantly higher risk of incontinence (odds ratio 1.97; p < 0.001). The study is limited by the lack of central histopathological review and relatively short follow-up.

CONCLUSIONS AND CLINICAL IMPLICATIONS

In a large cohort, UH presence was associated with worse short- to mid-term oncological outcomes after RARP. IDC independently predicted a higher rate of aRT receipt. At 1-yr follow-up after RP, patients with UH had three times higher risk of erectile dysfunction post RARP; CP was associated with a twofold higher incontinence rate.

PATIENT SUMMARY

Among patients with prostate cancer who undergo robot-assisted surgery to remove the prostate, those with less common types of prostate cancer have worse results for cancer control, erection, and urinary continence and a higher probability of receiving additional radiotherapy after surgery.

Urinary Continence Recovery after Retzius-Sparing Robot Assisted Radical Prostatectomy and Adjuvant Radiation Therapy

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) allows the preservation of the structures advocated to play a crucial role in the continence mechanism. This study aims to evaluate the association between adjuvant radiation therapy (aRT) and urinary continence (UC) recovery after RS-RARP. For the purpose of the current study, all patients submitted to RS-RARP for prostate cancer (PCa) at a single high-volume European institution between January 2010 and December 2021 were identified. Only patients that harbored pT2 stage with positive surgical margins or pT3/pN1 stage with or without positive surgical margins were included in the analyses. Two groups of patients were identified as follows: patients who had undergone aRT and patients submitted to observation (no-aRT patients). As per definition, aRT was delivered within 1-6 months after surgery. After 1:1 propensity score matching, 124 aRT patients were compared with 124 no-aRT patients who continued standard follow-up protocol after surgery. UC recovery was 81 vs. 84% in aRT vs. no-aRT patients (p = 0.7). In multivariable Cox regression analyses, aRT did not reach the independent predictor status for UC recovery at 12 months. In the subgroup analysis including only aRT patients, only the nerve-sparing technique was independently associated with UC recovery at 12 months. Conversely, the type of aRT (IMRT/VMAT vs. 3D-CRT) did not reach the independent predictor status for UC recovery at 12 months. The current study is the first to address the association between aRT and UC recovery in patients treated with RS-RARP for PCa. Based on our data, aRT is not associated with worse UC recovery. In the cohort of patients treated with aRT, the nerve-sparing technique independently predicted UC recovery.

Retzius-sparing robot-assisted radical prostatectomy after previous trans-urethral resection of the prostate: Assessment of functional and oncological outcomes

BACKGROUND

no data exist concerning functional and oncological outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP), in patients previously treated with trans-urethral resection of the prostate (p-TURP), for benign prostate obstruction. Our study addressed the impact of p-TURP on immediate and 12-months urinary continence recovery (UCR), as well as peri-operative outcomes and surgical margins, after RS-RARP.

METHODS

all patients treated with RS-RARP for prostate cancer at a single high-volume European institution, between 2010 and 2021, were identified and stratified according to p-TURP status. Logistic, Poisson and Cox regression models were performed.

RESULTS

Of 1386 RS-RARP patients, 99 (7%) had history of p-TURP. Between p-TURP and no-TURP patients no differences were detected regarding both intra- and post-operative complications (p values = 0.9). The rates of immediate UCR were 40 vs 67% in p-TURP vs no-TURP patients (p < 0.001). At 12 months from RS-RARP, the rates of UCR were 68 vs 94% in p-TURP vs no-TURP patients (p < 0.001). At multivariable logistic and Cox regression models, p-TURP was independently associated, respectively, with lower immediate (odds ratio [OR]: 0.32, p < 0.001) and 12-months UCR (hazard ratio: 0.54, p < 0.001). At multivariable Poisson analyses, p-TURP predicted longer operative time (rate ratio: 1.08, p < 0.001) but not longer length of stay or time to catheter removal (p values > 0.05). Positive surgical margins rates were 23 vs 17% in p-TURP vs no-TURP patients (p = 0.1), which translated in a non-statistically significant multivariable OR of 1.14 (p = 0.6).

CONCLUSIONS

p-TURP does not increase surgical morbidity but portends longer operative time and worse urinary continence after RS-RARP.

The spread of retzius-sparing robotic prostatectomy: an update after 10 years

PURPOSE OF REVIEW

Objective of our work is to provide an update of the state of the art concerning Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and to give a possible vision on the future developments of this new approach.

RECENT FINDINGS

A nonsystematic literature review has been conducted, finding 27 comparative studies and 24 reviews published up to April 15, 2023. Most of these studies confirm the advantages of RS-RARP relative to standard RARP mainly on early continence recovery. Conversely, discordant findings are reported for the benefit of RS-RARP on late continence recovery. Uncertainty is still present on the impact on positive surgical margins (PSMs), but this statement is based on low level of evidence. Several data concerning the learning curve have shown the safety of RS-RARP, but the need of adequate tutoring. Recent studies also confirmed the feasibility of RS-RARP in the setting of high-risk prostate cancer (PCa), large prostate volume, patients with an history of benign prostatic hyperplasia surgery and patients with a transplanted kidney. Atypical advantages can be also seen in the reduction of risk of postoperative inguinal hernias and in case of concomitant rectal resection.

SUMMARY

Retzius-sparing RARP has been confirmed to be one of the standard approaches for the treatment of PCa, with well documented advantages and uncertainty on PSMs.

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.

Challenging cases in high-risk prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy

OBJECTIVE

To evaluate the relationship between enlarged prostate, bulky median lobe (BML) or prior benign prostatic hyperplasia (BPH) surgery and perioperative functional, and oncological outcomes in high-risk (HR) prostate cancer (PCa) patients treated with Retzius-sparing robot-assisted radical prostatectomy (RS-RARP).

METHODS

320 HR-PCa patients treated with RS-RARP between 2011 and 2020 at a single high-volume center. The relationship between prostate volume, BML, prior BPH surgery and perioperative outcomes, Clavien-Dindo (CD) grade ≥ 2 90-day postoperative complications, positive surgical margins (PSMs), and urinary continence (UC) recovery was evaluated respectively in multivariable linear, logistic and Cox regression models. Complications were collected according to the standardized methodology proposed by EAU guidelines. UC recovery was defined as the use of zero or one safety pad.

RESULTS

Overall, 5.9% and 5.6% had respectively a BML or prior BPH surgery. Median PV was 45 g (range: 14-300). The rate of focal and non-focal PSMs was 8.4% and 17.8%. 53% and 10.9% patients had immediate UC recovery and CD ≥ 2. The 1- and 2-yr UC recovery was 84 and 85%. PV (p = 0.03) and prior BPH surgery (p = 0.02) was associated with longer operative time. BML was independent predictor of time to bladder catheter removal (p = 0.001). PV was independent predictor of PSMs (OR: 1.02; p = 0.009). Prior BPH surgery was associated with lower UC recovery (HR: 0.5; p = 0.03).

CONCLUSION

HR-PCa patients with enlarged prostate have higher risk of PSMs, while patients with prior BPH surgery have suboptimal UC recovery. These findings should help physicians for accurate preoperative counseling and to improve surgical planning in case of HR-PCa patients with challenging features.

Retzius-sparing Robot-assisted Radical Prostatectomy in High-risk Prostate Cancer Patients: Results from a Large Single-institution Series

Background

Retzius-sparing (RS) robot-assisted radical prostatectomy represents a valid surgical treatment option for prostate cancer (PCa) patients. However, the available evidence on the role of RS in high-risk (HR) PCa setting is sparse.

Objective

To describe our RS technique for HR-PCa patients and to evaluate intra-, peri-, and postoperative oncological and functional outcomes.

Design, setting, and participants

A total of 340 D’Amico HR-PCa patients underwent RS at a single high-volume centre between 2011 and 2020.

Surgical procedure

Surgical procedures were performed by five experienced robotic surgeons.

Measurements

Complications were collected according to the standardised methodology proposed by the European Association of Urology guidelines. Postoperative outcomes were evaluated in patients with complete follow-up data (n = 320). Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values of ≥0.2 ng/ml. Urinary continence (UC) recovery was defined as the use of zero or one safety pad. Kaplan-Meier and multivariable logistic and Cox regression models were performed.

Results and limitations

Fourteen patients (4%) experienced intraoperative complications and 52 90-d complications occurred in 44 patients (14%), of whom 24 had Clavien-Dindo 3a/b. Final pathology reported 49% International Society of Urological Pathology (ISUP) grade 4–5, 55% ≥pT3a, and 28.8% positive surgical margins (PSMs; 9.4% focal and 19.4% extended PSMs). The median follow-up was 47 mo. Overall, 35.3% and 1.3% harboured BCR and died from PCa. At 4 yr of follow-up, BCR-free survival and additional treatment-free survival were 63.6% and 56.6%, respectively. ISUP 4–5 at biopsy (odds ratio [OR]: 2.6), prostate volume (OR: 1.03), partial or full nerve sparing (OR: 1.9), and full bladder neck preservation (OR: 2.2) were independent predictors of PSMs. Pathological ISUP 4–5 (hazard ratio [HR]: 1.5) and PSMs (HR: 2.3) were independent predictors of BCR. Pathological ISUP 4–5 (HR: 1.5), PSMs (HR: 2.4), pT ≥3b (HR: 1.8), and pN ≥1 (HR: 1.8) were independent predictors of additional treatment. Immediate UC recovery was recorded in 53% patients. The 1- and 2-yr UC recovery and erectile function recovery were, respectively, 84% and 85%, and 43% and 50%.

Conclusions

RS in HR-PCa patients allows optimal intra-, peri-, and postoperative outcomes. The RS approach should be considered a valid surgical treatment option for HR-PCa patients in expert hands.

Patient summary

Relying on the largest cohort of high-risk prostate cancer patients treated with Retzius sparing (RS), we observed that the RS approach is safe and allows optimal cancer control, without significantly compromising functional outcomes.

Simultaneous robotic partial nephrectomy for bilateral renal masses

PURPOSE

There is currently no consensus regarding the optimal treatment strategy for patients presenting with synchronous bilateral renal masses. The decision to perform bilateral procedures on the same intervention or in staged procedures is debated. The aim of this manuscript is to analyse the outcomes of simultaneous robot-assisted partial nephrectomy (RAPN) in a series of patients with bilateral renal masses treated at five Italian robotic institutions.

METHODS

Data from a prospectively maintained multi-institutional database on patients subjected to simultaneous RAPN between November 2011 and July 2019 were reviewed. RAPNs were performed with da Vinci Si or Xi surgical system by expert robotic surgeons. Baseline demographics and clinical features, peri- and post-operative data were collected.

RESULTS

Overall, 27 patients underwent simultaneous bilateral RAPN, and 54 RAPNs were performed without need of conversion; median operative time was 250 minutes, median estimated blood loss was 200 mL. Renal artery clamping was needed for 27 (50%) RAPNs with a median warm ischemia time of 15 minutes and no case of acute kidney injury. Complications were reported in 7 (25.9%) patients, mainly represented by Clavien 2 events (6 blood transfusions). Positive surgical margins were assessed in 2 (3.7%) of the renal cell carcinoma. At the median follow-up of 30 months, recurrence-free survival was 100%.

CONCLUSION

Our data showed that, in selected patients and expert hands, simultaneous bilateral RAPNs could be a safe and feasible procedure with promising results for the treatment of bilateral synchronous renal masses.

Robotic-assisted, laparoscopic, and open radical cystectomy: surgical data of 1400 patients from The Italian Radical Cystectomy Registry on intraoperative outcomes

Introduction

The Italian Radical Cystectomy Registry (Registro Italiano Cistectomie – RIC) aimed to analyse outcomes of a multicenter series of patients treated with radical cystectomy (RC) for bladder cancer.

Material and methods

An observational, prospective, multicenter, cohort study was performed to collect data from RC and urinary diversion via open (ORC), laparoscopic (LRC), or robotic-assisted (RARC) techniques performed in 28 Italian Urological Departments. The enrolment was planned from January 2017 to June 2020 (goal: 1000 patients), with a total of 1425 patients included. Chi-square and t-tests were used for categorical and continuous variables. All tests were 2-sided, with a significance level set at p <0.05.

Results

Overall median operative-time was longer in RARCs (390 minutes, IQR 335–465) than ORCs (250, 217–309) and LRCs (292, 228–350) (p <0.001). Lymph node dissection (LND) was performed more frequently in RARCs (97.1%) and LRCs (93.5%) than ORCs (85.6%) (p <0.001), with extended-LND performed 2-fold more frequently in RARCs (61.6%) (p <0.001). The neobladder rate was significantly higher (more than one-half) in RARCs. The median estimated blood loss (EBL) rate was lower in RARCs (250 ml, 165–400) than LRCs (330, 200–600) and ORCs (400, 250–600) (p <0.001), with intraoperative blood transfusion rates of 11.4%, 21.7% and 35.6%, respectively (p <0.001). The conversion to open rate was slightly higher in RARCs (6.8%) than LRCs (4.3%). Intraoperative complications occurred in 1.3% of cases without statistically significant differences among the approaches.

Conclusions

Data from the RIC confirmed the need to collect as much data as possible in a multicenter manner. RARCs proves to be feasible with perioperative complication rates that do not differ from the other approaches.

Applicability of COVID-19 Pandemic Recommendations for Urology Practice: Data from Three Major Italian Hot Spots (BreBeMi)

BACKGROUND

Lombardy has been the first and one of the most affected European regions during the first and second waves of the novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]).

OBJECTIVE

To evaluate the impact of coronavirus disease 2019 (COVID-19) on all urologic activities over a 17-wk period in the three largest public hospitals in Lombardy located in the worst hit area in Italy, and to assess the applicability of the authorities' recommendations provided for reorganising urology practice.

DESIGN SETTING AND PARTICIPANTS

A retrospective analysis of all urologic activities performed at three major public hospitals in Lombardy (Brescia, Bergamo, and Milan), from January 1 to April 28, 2020, was performed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Join-point regression was used to identify significant changes in trends for all urologic activities. Average weekly percentage changes (AWPCs) were estimated to summarise linear trends. Uro-oncologic surgeries performed during the pandemic were tabulated and stratified according to the first preliminary recommendations by Stensland et al (Stensland KD, Morgan TM, Moinzadeh A, et al. Considerations in the triage of urologic surgeries during the COVID-19 pandemic. Eur Urol 2020;77:663-6) and according to the level of priority recommended by European Association of Urology guidelines.

RESULTS AND LIMITATIONS

The trend for 2020 urologic activities decreased constantly from weeks 8-9 up to weeks 11-13 (AWPC range -41%, -29.9%; p < 0.001). One-third of uro-oncologic surgeries performed were treatments that could have been postponed, according to the preliminary urologic recommendations. High applicability to recommendations was observed for non-muscle-invasive bladder cancer (NMIBC) patients with intermediate/emergency level of priority, penile and testicular cancer patients, and upper tract urothelial cell carcinoma (UTUC) and renal cell carcinoma (RCC) patients with intermediate level of priority. Low applicability was observed for NMIBC patients with low/high level of priority, UTUC patients with high level of priority, prostate cancer patients with intermediate/high level of priority, and RCC patients with low level of priority.

CONCLUSIONS

During COVID-19, we found a reduction in all urologic activities. High-priority surgeries and timing of treatment recommended by the authorities require adaptation according to hospital resources and local incidence.

PATIENT SUMMARY

We assessed the urologic surgeries that were privileged during the first wave of coronavirus disease 2019 (COVID-19) in the three largest public hospitals in Lombardy, worst hit by the pandemic, to evaluate whether high-priority surgeries and timing of treatment recommended by the authorities are applicable. Pandemic recommendations provided by experts should be tailored according to hospital capacity and different levels of the pandemic.

Protocol of the Italian Radical Cystectomy Registry (RIC): a non-randomized, 24-month, multicenter study comparing robotic-assisted, laparoscopic, and open surgery for radical cystectomy in bladder cancer

Background

Bladder cancer is the ninth most common type of cancer worldwide. In the past, radical cystectomy via open surgery has been considered the gold-standard treatment for muscle invasive bladder cancer. However, in recent years there has been a progressive increase in the use of robot-assisted laparoscopic radical cystectomy. The aim of the current project is to investigate the surgical, oncological, and functional outcomes of patients with bladder cancer who undergo radical cystectomy comparing three different surgical techniques (robotic-assisted, laparoscopic, and open surgery). Pre-, peri- and post-operative factors will be examined, and participants will be followed for a period of up to 24 months to identify risks of mortality, oncological outcomes, hospital readmission, sexual performance, and continence.

Methods

We describe a protocol for an observational, prospective, multicenter, cohort study to assess patients affected by bladder neoplasms undergoing radical cystectomy and urinary diversion. The Italian Radical Cystectomy Registry is an electronic registry to prospectively collect the data of patients undergoing radical cystectomy conducted with any technique (open, laparoscopic, robotic-assisted). Twenty-eight urology departments across Italy will provide data for the study, with the recruitment phase between 1st January 2017-31st October 2020. Information is collected from the patients at the moment of surgical intervention and during follow-up (3, 6, 12, and 24 months after radical cystectomy). Peri-operative variables include surgery time, type of urinary diversion, conversion to open surgery, bleeding, nerve sparing and lymphadenectomy. Follow-up data collection includes histological information (e.g., post-op staging, grading, and tumor histology), short- and long-term outcomes (e.g., mortality, post-op complications, hospital readmission, sexual potency, continence etc).

Discussion

The current protocol aims to contribute additional data to the field concerning the short- and long-term outcomes of three different radical cystectomy surgical techniques for patients with bladder cancer, including open, laparoscopic, and robot-assisted. This is a comparative-effectiveness trial that takes into account a complex range of factors and decision making by both physicians and patients that affect their choice of surgical technique.

Trial registration

ClinicalTrials.gov, NCT04228198. Registered 14th January 2020- Retrospectively registered.

Retzius-sparing robot-assisted radical prostatectomy: early learning curve experience in three continents

OBJECTIVE

To assess the effect of surgical experience on peri-operative, functional and oncological outcomes during the first 50 Retzius-sparing robot-assisted radical prostatectomy (RsRARP) cases performed by surgeons naïve to this novel approach.

MATERIALS AND METHODS

We retrospectively evaluated the initial cases operated by 14 surgeons in 12 different international centres. Pre-, peri- and postoperative features of the first 50 patients operated by each surgeon in all the participating centres were collected. The effect of surgical experience on peri-operative, functional and oncological outcomes was firstly evaluated after stratification by level of surgical experience (initial [≤25 cases] and expert [>25 cases]) and after using locally weighted scatterplot smoothing to graphically explore the relationship between surgical experience and the outcomes of interest.

RESULTS

We evaluated 626 patients. The median follow-up was 13 months in the initial group and 9 months in the expert group (P = 0.002). Preoperative features overlapped between the two groups. Shorter console time (140 vs 120 min; P = 0.001) and a trend towards lower complications rates (13 vs 5.5%; P = 0.038) were observed in the expert group. The relationship between surgical experience and console time, immediate urinary continence recovery and Clavien-Dindo grade ≥2 complications was linear, without reaching a plateau, after 50 cases. Conversely, a non-linear relationship was observed between surgical experience and positive surgical margins (PSMs).

CONCLUSIONS

In this first report of a multicentre experience of RsRARP during the learning curve, we found that console time, immediate urinary continence recovery and postoperative complications are optimal from the beginning and further quickly improve during the learning process, while PSM rates did not clearly improve over the first 50 cases.

Retzius-sparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes

OBJECTIVES

To summarize the current evidence on Retzius-sparing (RS)-robot-assisted radical prostatectomy (RARP) and to compare its oncological, peri-operative and functional outcomes with those of standard retropubic RARP (S-RARP).

MATERIALS AND METHODS

After establishing an a priori protocol, a systematic electronic literature search was conducted in January 2019 using the Medline (via PubMed), Embase (via Ovid) and Cochrane databases. The search strategy relied on the 'PICO' (Patient Intervention Comparison Outcome) criteria and article selection was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only studies reporting the oncological and functional outcomes of RARP (as determined by type of procedure [RS-RARP vs S-RARP]) were considered for inclusion. Risk of bias and study quality were assessed. Finally, peri-operative and functional outcomes were recorded and analysed.

RESULTS

A shorter operating time was associated with RS-RARP (weighted mean difference [WMD] 14.7 min, 95% confidence interval [CI] -28.25, 1.16; P = 0.03), whereas no significant difference was found in terms of estimated blood loss (WMD 1.45 mL, 95% CI -31.18, 34.08; P = 0.93). Also, no significant difference between the two groups was observed for overall (odds ratio [OR] 0.86, 95% CI 0.40, 1.85; P = 0.71) and major (Clavien >3; OR 0.88, 95% CI 0.30, 2.57) postoperative complications; however, the likelihood of positive surgical margins (PSMs) was lower for the S-RARP group (rate 15.2% vs 24%; OR 1.71, 95% CI 1.12, 2.60; P = 0.01). The cumulative analysis showed a statistically significant advantage for RS-RARP in terms of continence recovery at 1 month (OR 2.54, 95% CI 1.16, 5.53; P = 0.02), as well as at 3 months (OR 3.86, 95% CI 2.23, 6.68; P < 0.001), 6 months (OR 3.61, 95% CI 1.88, 6.91; P = 0.001), and 12 months (OR 7.29, 95% CI 1.89, 28.13; P = 0.004).

CONCLUSION

Our analysis confirms that RS-RARP is a safe and feasible alternative to S-RARP. This novel approach may be associated with faster and higher recovery of continence, without increasing the risk of complications. One caveat might be the higher risk of PSMs, and this can be regarded as a current pitfall of the technique, probably related to an expected learning curve.

Robot assisted radical prostatectomy in kidney transplant recipients: surgical, oncological and functional outcomes of two different robotic approaches

Background:

To date, few series on robot-assisted radical prostatectomy (RARP) in kidney transplant recipients (KTRs) have been published.

Purpose:

To report the experience of two referral centers adopting two different RARP approaches in KTRs. Surgical, oncological and functional results were primary outcomes evaluated in the study.

Material and methods:

We retrospectively analyzed data from 9 KTRs who underwent transperitoneal RARP or Retzius-sparing RARP for PCa from October 2012 to April 2016. Data were reported as median and interquartile range (IQR). Pre- and postoperative outcomes were compared by non-parametric Wilcoxon signed-rank test. Significant differences were accepted when p ≤ 0.05. Overall survival was assessed using Kaplan-Meier method.

Results:

Four KTRs underwent a T-RARP and 5 a RS-RARP. Patient median age was 60 (56-63) years. Charlson comorbidity index was 6 (5-6). Preoperative median PSA was 5.6 (5-15) ng / mL. Preoperative Gleason score (GS) was 6 in 5 patients, 7 (3 + 4) in 3, and 8 (4 + 4) in one. Pre- and postoperative creatinine were 1.17 (1.1; 1.4) and 1.3 (1.07; 1.57) mg / dL (p = 0.237), while eGFR was 66 (60-82) and 62 (54-81) mL / min / 1.73m2 (p = 0.553), respectively. One (11.1%) Clavien-Dindo grade II complication occurred. Two extended template lymphadenectomies were performed, both with nodal invasion. These two patients experienced a biochemical recurrence and were subjected to RT. Two patients (22.2%) had PSMs. Median follow-up was 42 months. Seven patients (77.8%) were continent, 5 (55.6%) were potent. Two (22.2%) patients died during follow-up for oncologic unrelated causes.

Conclusions:

Our series suggests that both RARP approaches are safe and feasible techniques in KTRs for PCa.

Technical features and the demonstrated advantages of the Retzius sparing robotic prostatectomy

OBJECTIVE

Robot-assisted laparoscopic  radical prostatectomy (RARP) is nowadays considered  the main surgical option for localized prostate cancer (PCa). We recently developed a new approach for RARP  avoiding all the Retzius structures involved in continence  and potency preservation, the so called Retzius-sparing  technique (RSP). The objective of the paper is to report technical aspects and functional results of RSP.  METHODS: We evaluated our data and available literature  regarding RSP, functional results and advantages.  RESULTS: RSP is oncologically safe and guarantee high early continence rates.

CONCLUSION

Long-term, prospective, comparative,  and possibly randomized studies are needed but RSP is  now spreading all over the world thanks to the different advantages that offers to patients. The most recognized benefit is surely the achievement of early continence, as well documented in multiple studies and papers, without compromising the oncological outcomes.

Prostatic Artery Embolization as an Alternative to Indwelling Bladder Catheterization to Manage Benign Prostatic Hyperplasia in Poor Surgical Candidates

PURPOSE

To prospectively assess discontinuation of indwelling bladder catheterization (IBC) and relief of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) following prostate artery embolization (PAE) in poor surgical candidates.

METHODS

Patients ineligible for surgical intervention were offered PAE after at least 1 month of IBC for management of urinary retention secondary to BPH; exclusion criteria for PAE included eligibility for surgery, active bladder cancer or known prostate cancer. Embolization technical and clinical success were defined as bilateral prostate embolization and removal of IBC, respectively. Patients were followed for at least 6 months and evaluated for International Prostate Symptom Score, quality of life, prostate size and uroflowmetric parameters.

RESULTS

A total of 43 patients were enrolled; bilateral embolization was performed in 33 (76.7%), unilateral embolization was performed in 8 (18.6%), and two patients could not be embolized due to tortuous and atherosclerotic pelvic vasculature (4.7%). Among the patients who were embolized, mean prostate size decreased from 75.6 ± 33.2 to 63.0 ± 23.2 g (sign rank p = 0.0001, mean reduction of 19.6 ± 17.3%), and IBC removal was achieved in 33 patients (80.5%). Clavien II complications were reported in nine patients (21.9%) and included urinary tract infection (three patients, 7.3%) and recurrent acute urinary retention (six patients, 14.6%). Nine patients (22.0%) experienced post-embolization syndrome.

CONCLUSIONS

PAE is a safe and feasible for the relief of LUTS and IBC in highly comorbid patients without surgical treatment options.

Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project)

OBJECTIVES

To compare simple enucleation (SE) and standard partial nephrectomy (SPN) in terms of surgical results in a multicenter dataset (RECORd Project).

MATERIALS AND METHODS

patients treated with nephron sparing surgery (NSS) for clinical T1 renal tumors between January 2009 and January 2011 were evaluated. Overall, 198 patients who underwent SE were retrospectively matched to 198 patients who underwent SPN. The SPN and SE groups were compared regarding intraoperative, early post-operative and pathologic outcome variables. Multivariable analysis was applied to analyze predictors of positive surgical margin (PSM) status.

RESULTS

SE was associated with similar WIT (18 vs 17.8 min), lower intraoperative blood loss (177 vs 221 cc, p = 0.02) and shorter operative time (121 vs 147 min; p < 0.0001). Surgical approach (laparoscopic vs. open), tumor size and type of indication (elective/relative vs absolute) were associated with WIT >20 min. The incidence of PSM was significantly lower in patients treated with SE (1.4% vs 6.9%; p = 0.02). At multivariable analysis, PSM was related to the surgical technique, with a 4.7-fold increased risk of PSM for SPN compared to SE. The incidence of overall, medical and surgical complications was similar between SE and SPN.

CONCLUSIONS

Type of NSS technique (SE vs SPN) adopted has a negligible impact on WIT and postoperative morbidity but SE seems protective against PSM occurrence.

A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery

Robot-assisted laparoscopic prostatectomy (RALP) has been disseminated widely, changing the knowledge of surgical anatomy of the prostate. The aim of our study is to demonstrate the feasibility of a new, purely intrafascial approach. The Bocciardi approach for RALP passes through the Douglas space, following a completely intrafascial plane without any dissection of the anterior compartment, which contains neurovascular bundles, Aphrodite's veil, endopelvic fascia, the Santorini plexus, pubourethral ligaments, and all of the structures thought to play a role in maintenance of continence and potency. In this case series, we present our first five patients undergoing the Bocciardi approach for RALP. We report the results of our technique in three patients following two unsuccessful attempts. No perioperative major complication was recorded. Pathologic stage was pT2c in two patients and pT2a in one patient, with no positive surgical margin. The day after removing the catheter, two of the three patients reported use of a single, small safety pad, and one patient was discharged without any pad. One patient reported an erection the day after removing the catheter. The anatomic rationale for better results compared with traditional RALP is strong, but well-designed studies are needed to evaluate the advantages of our technique.