Robotic surgery for bowel endometriosis: a multidisciplinary management of a complex entity

BACKGROUND

Bowel endometriosis impacts quality of life. Treatment requires complex surgical procedures with associated morbidity. Precision approach with robotic surgery leads to organ preservation. Bowel endometriosis requires a multidisciplinary management to improve patient outcomes. This study evaluates perioperative outcomes of bowel endometriosis undergoing multidisciplinary planning and robotic surgery.

METHODS

Consecutive cases of multidisciplinary robotic bowel endometriosis procedures (January 2021-December 2022) were evaluated from a prospectively maintained database in a national endometriosis accredited centre. Patients were managed through a multidisciplinary setting including gynaecologists, colorectal robotic surgeons, and other specialists. Dyschezia (menstrual and non-cyclical) and quality of life were assessed pre- and postoperatively (6 months) through validated questionnaires.

RESULTS

Sixty-eight consecutive cases of robotic bowel endometriosis were included. Median age was 35.0 (30.2-42.0) years. Median body mass index was 24.0 (21.0-26.7) kg/m2. Procedures performed were 48 (70.6%) shavings, 11 (16.2%) deep shavings, 3 (4.4%) disc excisions, and 6 (8.8%) segmental resections. One (1.5%) patient required temporary stoma. Median operating time was 150 (120-180) min. There were no conversions/return to theatre postoperatively. Median endometriotic nodule size was 25.0 (15.5-40.0) mm. Two (2.9%) patients developed postoperative complications. Median length of postoperative stay was 2 (2-4) days. Median follow-up was 12 (7-17) months. One (1.5%) patient recurred. Median menstrual dyschezia score improved from 5.0 (2.0-8.0) to 1.0 (0.0-5.7). Median non-cyclical dyschezia significantly improved (p < 0.001) from 1.0 (0.0-5.7) to 0.0 (0.0-2.0). Median quality of life score improved from 52.5 (35.0-70.0) to 74.5 (60.0-80.0).

CONCLUSIONS

Robotic multidisciplinary approach to bowel endometriosis provides good perioperative outcomes with improvement of dyschezia and quality of life.

A Multicenter Study of 2-year Outcomes Following Hyperthermia Therapy with Mitomycin C in Treating Non-Muscle Invasive Bladder Cancer: HIVEC-E

INTRODUCTION: High grade, non-muscle invasive bladder cancer (NMIBC) is treated with intravesical Bacillus Calmette–Guérin. Chemohyperthermia therapy (CHT) may be a novel alternative therapy for the treatment of NMIBC. OBJECTIVE: To evaluate the recurrence-free survival (RFS) of patients treated with CHT using the Combat bladder recirculation system (BRS) for NMIBC. METHODS: This was a prospective multi-institutional study of 1,028 consecutive patients with NMIBC undergoing CHT between 2012 and 2020. A total of 835 patients were treated with CHT and Mitomycin C (MMC). Disease was confirmed on transurethral resection of bladder tumor (TURBT). Patients with NMIBC underwent CHT with MMC. Follow-up included cystoscopy and subsequent TURBT if recurrence/progression was suspected. The primary endpoint was RFS. Secondary endpoints were progression-free survival (PFS) and adverse events from CHT. RESULTS AND LIMITATIONS: Median follow up was 22.4 months (Interquartile range (IQR): 12.8 –35.8). Median age was 70.4 years (IQR: 62.1 –78.6). A total of 557 (66.7%), 172 (20.6) and 74 (8.9%) of patients were classified to BCG naïve, BCG unresponsive and BCG refractory/relapsing/intolerant, respectively. The RFS at 12 months and 24 months for BCG naïve was 87.6% (95% CI 85.0% - 90.4%) and 75.0% (95% CI 71.3% - 78.8%), respectively. The RFS at 12 months and 24 months for BCG unresponsive cohort was 78.1% (95% CI 72.0% - 84.7%) and 57.4% (95% CI 49.7% - 66.3%), respectively. The RFS at 24 months for the BCG unresponsive cohort for CIS positive and CIS negative patients were 43.6% (95% CI 31.4% –60.4%) and 64.5% (95% CI 55.4% - 75.1%), respectively. Minor events occurred in 216 (25.6%) of patients and severe events occurred in 17 (2.0%). CONCLUSIONS: CHT with MMC using the Combat BRS is effective in the medium term and has a favorable adverse event profile.

Adjuvant Intravesical Chemohyperthermia Versus Passive Chemotherapy in Patients with Intermediate-risk Non-muscle-invasive Bladder Cancer (HIVEC-II): A Phase 2, Open-label, Randomised Controlled Trial

BACKGROUND

Adjuvant intravesical chemotherapy following tumour resection is recommended for intermediate-risk non-muscle-invasive bladder cancer (NMIBC).

OBJECTIVE

To assess the efficacy and safety of adjuvant intravesical chemohyperthermia (CHT) for intermediate-risk NMIBC.

DESIGN, SETTING, AND PARTICIPANTS

HIVEC-II is an open-label, phase 2 randomised controlled trial of CHT versus chemotherapy alone in patients with intermediate-risk NMIBC recruited at 15 centres between May 2014 and December 2017 (ISRCTN 23639415). Randomisation was stratified by treating hospital.

INTERVENTIONS

Patients were randomly assigned (1:1) to adjuvant CHT with mitomycin C at 43°C or to room-temperature mitomycin C (control). Both treatment arms received six weekly instillations of 40 mg of mitomycin C lasting for 60 min.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was 24-mo disease-free survival as determined via cystoscopy and urinary cytology. Analysis was by intention to treat.

RESULTS

A total of 259 patients (131 CHT vs 128 control) were randomised. At 24 mo, 42 patients (32%) in the CHT group and 49 (38%) in the control group had experienced recurrence. Disease-free survival at 24 mo was 61% (95% confidence interval [CI] 51-69%) in the CHT arm and 60% (95% CI 50-68%) in the control arm (hazard ratio [HR] 0.92, 95% CI 0.62-1.37; log-rank p = 0.8). Progression-free survival was higher in the control arm (HR 3.44, 95% CI 1.09-10.82; log-rank p = 0.02) on intention-to-treat analysis but was not significantly higher on per-protocol analysis (HR 2.87, 95% CI 0.83-9.98; log-rank p = 0.06). Overall survival was similar (HR 2.55, 95% CI 0.77-8.40; log-rank p = 0.09). Patients undergoing CHT were less likely to complete their treatment (n =75, 59% vs n = 111, 89%). Adverse events were reported by 164 patients (87 CHT vs 77 control). Major (grade III) adverse events were rare (13 CHT vs 7 control).

CONCLUSIONS

CHT cannot be recommended over chemotherapy alone for intermediate-risk NMIBC. Adverse events following CHT were of low grade and short-lived, although patients were less likely to complete their treatment.

PATIENT SUMMARY

The HIVEC-II trial investigated the role of heated chemotherapy instillations in the bladder for treatment of intermediate-risk non-muscle-invasive bladder cancer. We found no cancer control benefit from heated chemotherapy instillations over room-temperature chemotherapy. Adverse events following heated chemotherapy were low grade and short-lived, although these patients were less likely to complete their treatment.

Robotic total pelvic exenteration for rectal cancer: case report and review of literature

We describe a case report of a robotic total pelvic exenteration (TPE) performed for a locally advanced rectal cancer at our institution in August 2018. Technical details and comparison with published literature are discussed. A 62-year-old patient with a locally advanced low rectal cancer T4N1cM0 with extramural vascular invasion (EMVI) underwent an elective robotic pelvic clearance performed by the urology and colorectal teams. He received neoadjuvant long-course chemo-radiotherapy to downstage the rectal cancer. The primary tumour was T4N1c with involvement of the bladder (trigone area) and prostate. After neoadjuvant therapy, MRI scan showed tumour regression grade 4 (TRG4). The patient underwent single docking totally robotic pelvic clearance. Patient's body mass index (BMI) was 32. The operative time was 400 minutes with the docking time of 15 minutes. There were no intraoperative complications, and the blood loss was 100ml. Histology was ypT4b, ypN1b, ypMx with 2/9 positive lymph nodes, and there was a complete resection by >1mm at all margins. The postoperative complications were ileus and urinary tract infection. Length of stay was 11 days complicated by prolonged ileus requiring total parenteral nutrition (TPN). The 30-day follow-up had no postoperative complications or readmission. The robotic approach is safe and feasible for multiorgan resections for locally advanced pelvic cancers, with curative intent. The literature supports it by highlighting the advantages of robotic pelvic surgery: better access, stable platform, quick inter-specialty change of operator by use of dual console and superior visualisation.

A single institution experience: Robotic-assisted laparoscopic renal calyceal diverticulectomies, heminephrectomy and bladder diverticulectomies

Introduction:

The use of a robotic surgical system has transformed modern urological surgeries. There is little reported, however, on the use of robotic surgical systems in the management of benign urological diseases. We aim to report our experience in robotic-assisted surgery in renal calyceal diverticulectomies, heminephrectomy and bladder diverticulectomies.

Methodology:

We retrospectively collected the data of patients who had robotic-assisted surgery in our institution from 1 January 2014 to 31 December 2019.

Results:

Over the last five years, our institution has performed over 1500 robotic-assisted urological surgeries. In this five-year period, four robotic surgeons have performed a total of 25 robotic assisted operations to treat benign urological diseases including three renal calyceal diverticulectomies, one heminephrectomy and two bladder diverticulectomies. All patients were satisfied with the outcomes of their surgery when reviewed at their follow up consultations.

Conclusion:

We report a very positive experience in using robotic surgical systems in managing our series of benign urological conditions in our hospital. We should not restrict the use of this tool to cancer surgery, but consider the technology in our surgical armamentarium for all aspects of our urological practice.

Major Urological Cancer Surgery for Patients is Safe and Surgical Training Should Be Encouraged During the COVID-19 Pandemic: A Multicentre Analysis of 30-day Outcomes

COVID-19 has resulted in the deferral of major surgery for genitourinary (GU) cancers with the exception of cancers with a high risk of progression. We report outcomes for major GU cancer operations, namely radical prostatectomy (RP), radical cystectomy (RC), radical nephrectomy (RN), partial nephrectomy (PN), and nephroureterectomy performed at 13 major GU cancer centres across the UK between March 1 and May 5, 2020. A total of 598 such operations were performed. Four patients (0.7%) developed COVID-19 postoperatively. There was no COVID-19–related mortality at 30 d. A minimally invasive approach was used in 499 cases (83.4%). A total of 228 cases (38.1%) were described as training procedures. Training case status was not associated with a higher American Society of Anesthesiologists (ASA) score (p =  0.194) or hospital length of stay (LOS; p >  0.05 for all operation types). The risk of contracting COVID-19 was not associated with longer hospital LOS (p =  0.146), training case status (p =  0.588), higher ASA score (p =  0.295), or type of hospital site (p =  0.303). Our results suggest that major surgery for urological cancers remains safe and training should be encouraged during the ongoing COVID-19 pandemic provided appropriate countermeasures are taken. These real-life data are important for policy-makers and clinicians when counselling patients during the current pandemic.

Patient summary

We collected outcome data for major operations for prostate, bladder, and kidney cancers during the COVID-19 pandemic. These surgeries remain safe and training should be encouraged during the ongoing pandemic provided appropriate countermeasures are taken. Our real-life results are important for policy-makers and clinicians when counselling patients during the COVID-19 pandemic.

Day case primary trans-urethral resection of bladder tumour (TURBT) as standard in a single UK centre. Should this be the new norm?

Objectives:

A retrospective study was conducted to examine the feasibility and safety of performing trans-urethral resection of bladder tumour (TURBT) in newly diagnosed patients as a day case operation.

Patients and methods:

All patients who underwent a primary TURBT over a 12 month period were included. Data were collected on patient demographics, tumour characteristics, day case vs. inpatient admission, indications for inpatient admission, re-admission rates within 28 days, and surrogate markers for quality of resection including recurrence rates.

Results:

A total of 172 patients were included. TURBT was performed as a day case procedure on 138 patients (80.2%). Rates of re-admission within 28 days were 7.2% and 5.9% in the day case and inpatient cohorts respectively. One hundred and thirty (75.6%) patients had non-muscle invasive bladder cancer (NMIBC). Of these, 84 (64.6%) were found to have detrusor muscle in their specimens, and 86 (66.2%) received peri-operative mitomycin C. Twelve month recurrence rates were 12%, 27% and 33% for low, intermediate and high-risk NMIBC respectively.

Conclusion:

This study shows that day case surgery for TURBT is feasible in the majority of patients, with a low rate of re-admission. Our data suggest that day case TURBT is suitable as standard practice in our institution and should be considered by others.

Level of evidence:

2b.

Continence and micturition: an anatomical basis

Urinary incontinence remains an important clinical problem worldwide, having a significant socio-economic, psychological, and medical burden. Maintaining urinary continence and coordinating micturition are complex processes relying on interaction between somatic and visceral elements, moderated by learned behavior. Urinary viscera and pelvic floor must interact with higher centers to ensure a functionally competent system. This article aims to describe the relevant anatomy and neuronal pathways involved in the maintenance of urinary continence and micturition. Review of relevant literature focusing on pelvic floor and urinary sphincters anatomy, and neuroanatomy of urinary continence and micturition. Data obtained from both live and cadaveric human studies are included. The stretch during bladder filling is believed to cause release of urothelial chemical mediators, which in turn activates afferent nerves and myofibroblasts in the muscosal and submucosal layers respectively, thereby relaying sensation of bladder fullness. The internal urethral sphincter is continuous with detrusor muscle, but its arrangement is variable. The external urethral sphincter blends with fibers of levator ani muscle. Executive decisions about micturition in humans rely on a complex mechanism involving communication between several cerebral centers and primitive sacral spinal reflexes. The pudendal nerve is most commonly damaged in females at the level of sacrospinous ligament. We describe the pelvic anatomy and relevant neuroanatomy involved in maintaining urinary continence and during micturition, subsequently highlighting the anatomical basis of urinary incontinence. Comprehensive anatomical understanding is vital for appropriate medical and surgical management of affected patients, and helps guide development of future therapies.

Role and rationale of gene therapy and other novel therapies in the management of NMIBC

Bladder cancer is the second most common urological malignancy with a one in 28 lifetime risk. Three-quarters of tumors are non-muscle-invasive (formerly termed superficial) at the time of presentation. Approximately half of all non-muscle-invasive bladder cancer (NMIBC) will recur and, depending on certain prognostic factors including grade, stage and presence of carcinoma in situ, a number will progress to muscle invasion. The standard of care for NMIBC is transurethral resection of bladder tumor (TURBT) to remove the mass lesion(s). Intravesical therapy of NMIBC post-TURBT therefore aims to delay/prevent recurrence and/or progression to muscle-invasive bladder cancer. While intravesical chemotherapy, such as mitomycin C, and immunotherapy, such as bacillus Calmette-Guérin are well established, there is current interest in novel therapies based on improved molecular understanding of bladder cancer. These novel therapies include gene therapy, using viral and non-viral vectors for transfer, monoclonal antibodies and direct tumoricidal viruses. While there is a sound theoretical basis for these therapies based on molecular targeting, there is little evidence in human studies that these therapies have clinical impact on NMIBC. However, it is certain that their use will be investigated further and they provide great hope for the future of NMIBC adjuvant therapy.

Trans-obturator tape: a single centre experience

AIM

To assess the clinical outcome of TOT tape for stress and mixed urinary incontinence in a single centre.

METHODS

From March 2002 to October 2006, 82 patients completed the study, all were evaluated at 3 and 12 months by physical examination and validated questionnaires. Seventy nine patients had the procedure under epidural anaesthesia and all women received antibiotics starting before surgery.

RESULTS

TOT was mostly performed as a day case surgery with short operative time of 22 minute (range 15-38 minute). A total of 62 (70.4%) patients were discharged from the hospital within a few hours (4.3 +/- 1.7 hours).

CONCLUSION

The TOT tape can safely be performed as a day-case procedure, which has a continence cure rate of approximately 80%. This figure is comparable with the more established TVT, however the TOT tape has a significantly lower morbidity in our experience.