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Robotic-assisted laparoscopic radical prostatectomy (RALP) is the gold standard surgical approach for treatment of prostate cancer. Prostate cancer is often comorbid with erectile dysfunction (ED), and a small subgroup of men undergoing RALP have an indwelling inflatable penile prosthesis (IPP). In men with IPPs, we perform two techniques at the time of RALP to preserve the pelvic reservoir. In the No Touch Technique, we leave the pseudocapsule of the reservoir intact, electing to dissect the pelvic sidewall and lateral prostatic attachments away from the pseudocapsule. In the Safe Mobilization Technique, we sharply open the pseudocapsule overlying the reservoir and relocate the reservoir out of the pelvis. We retrospectively analyzed 155 cases (Group IPP) from a cohort of 1000 men who underwent RALP. These cases were compared to a randomly selected control group comprising 455 men with PCa who underwent RALP without prior IPP placement (Group NoIPP). We compared perioperative and functional outcomes. The overall incidence of positive surgical margins (PSM) did not significantly differ between the groups (14% in Group IPP and 12% in Group NoIPP, p = 0.4). Furthermore, there was no statistically significant difference in the incidence of PSM at the bladder neck between Group IPP (5.3%) and Group NoIPP (3.4%), p = 0.1. Binomial logistic regression analysis did not find prior IPP placement to be a significant predictor of continence at 3 and 6 months or for BCR. All patients in Group IPP were able to successfully cycle their devices postoperatively and there were no reported device infections. The No Touch Technique and Safe Mobilization Technique are easy to perform and safe adjunct procedures at the time of RALP in men with pre-existing IPP., Competing Interests: Declarations. Conflict of interest: The authors have no relevant disclosures., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Purpose: Placement of a drain during robotic assisted partial nephrectomy (RAPN) and robotic assisted radical prostatectomy (RARP) is standard practice for many urologists and can aid in assessment and management of complications such as urine leak, lymphocele, or bleeding. However, drain placement can cause discomfort and delay patient discharge, with questionable benefit. We aim to assess the correlation between drain placement with post operative complications., Methods: The NSQIP targeted database was queried for patients who underwent RAPN or RARP from 2019 to 2021. Our primary outcomes included 30-day complication rates stratified by intraoperative drain placement. Secondary outcomes included procedure-specific complications, length of stay (LOS), and readmissions. Multivariable regression analyses, with Bonferroni correction, were performed for each post-operative complication., Results: We identified 4738 and 13,948 patients who underwent RAPN and RARP, respectively. Drains were not placed in 2258 (47.7%) and 6700 (48%) patients, respectively. On adjusted multivariable analysis in the RAPN cohort, omission of drain placement was associated with decreased LOS (β -0.45; 99.58% CI [-0.59, -0.32]) but no difference in overall complication rates. After adjusted analysis in the RARP cohort, omission of drain placement was associated with decreased risk of any complication (OR 0.73 [0.62-0.87]), infectious complication (OR 0.66 [0.49-0.89]), and LOS (β -0.30 [-0.37, -0.24])., Conclusions: Using a large contemporary database, this study demonstrates that omission of drains during RAPN and RARP was safe without increased risk of postoperative complications. Despite inherent selection bias in this cohort, our data suggests that routine drain placement is not necessary for these procedures., (© 2024. The Author(s).)

Definitive surgical treatment for prostate cancer continues to evolve with robotic prostatectomy being the preferred technique. This technique has led to decreased blood loss and transfusion rates. Although uncommon, this case report presents a rare incident of delayed inferior epigastric bleed from a port site after a robotic prostatectomy. Our case report aims to establish the first known algorithm to address port site bleeding after robotic prostatectomies. Having an established algorithmic approach to evaluate and treat patients with postoperative port site bleeding is paramount. Using the algorithm, this patient was stabilized, and bleeding was controlled with embolization., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (© 2024 The Authors.)

Background: We detail our approach and experience with a hybrid version of the endopelvic hood-sparing (HS) robot-assisted radical prostatectomy (RARP) using the da Vinci robotic platform. Materials and Methods: We retrospectively reviewed the records of 200 patients who underwent RARP by a single surgeon. Patients were propensity-matched into three cohorts depending on biopsy and prostatectomy Gleason Grade Groups: traditional retropubic (RP) ( n = 80), retzius-sparing (RS) ( n = 40), and HS ( n = 80). Patient characteristics and oncologic and functional outcomes were examined. Zero pads per day defined return of continence. Erections suitable for penetrative intercourse with/without medications defined return of sexual function. Results: Patient characteristics were similar between cohorts excluding prostate-specific antigen levels ( p = 0.014), which were significantly lower in the RS cohort (7.1 ± 5.3 ng/mL) compared with RP (9.2 ± 9.3 ng/mL) and HS (8.8 ± 8.9 ng/mL). Clinically significant positive margin rates were significantly higher ( p = 0.046) in the RS cohort (32.5%) compared with RP (17.5%) and HS (13.9%). Biochemical recurrence and metastasis rates were similar between all cohorts. Median time to continence was significantly lower for RS and HS-RARP ( p < 0.001) compared with RP-RARP at 1.3, 1.6, and 5.4 months, respectively. Median time to return of sexual function was significantly lower for RS and HS-RARP ( p < 0.001) compared with RP-RARP at 4.0, 7.7, and 15.1 months, respectively. Conclusions: Our hybrid HS-RARP approach provides functional outcomes similar to RS-RARP with the early oncologic control of traditional RP-RARP.

Objective: Benign prostatic hyperplasia is common in the aging population and frequently comorbid with localized prostate cancer. Large prostate volume places significant challenges in robotic prostatectomy including reduced mobility and visualization. The goal of this study is to evaluate the effect of prostate volume as a continuous variable on cancer specific outcomes., Methods: Three thousand four hundred and twenty five patients with localized prostate cancer at a single institution who underwent robotic prostatectomy were retrospectively reviewed. A number of preoperative, operative, and postoperative variables were collected to evaluate cancer specific outcomes including pathologic stage, tissue margins, and biochemical recurrence (BCR). Logistic regression models and univariate and multivariate analyses were implemented for pathologic stage T3 and BCR respectively., Results: The median follow up time was 52 months (IQR 18-95). 37.4% of the patients had a final pathologic stage of T3 or higher, 21.2% experienced positive surgical margins, and 24.7% of patients experienced BCR. Prostate size was a significant predictor of all three outcomes of interest. Increasing prostate size was protective against both higher pathologic stage and positive surgical margins (odds ratio = 0.989, 0.990 respectively, p < 0.001). There was a modest increase in the risk of BCR with increasing gland size (hazard ratio = 1.006, p < 0.001). These results were most significant for patients with Gleason Grade Groups 1 and 2 prostate cancer., Conclusion: Prostate size is a commonly determined clinical factor that effects both surgical planning and cancer specific outcomes. Increasing prostate size may offer protection against higher stage disease and positive surgical margins. While surgically challenging, favorable oncologic outcomes can be consistently achieved for patients with low-intermediate risk disease., (© 2024 The Author(s). The Prostate published by Wiley Periodicals LLC.)

Purpose: Incisional hernias are a frequent complication following robotic radical prostatectomy. Observational data in men undergoing robotic prostatectomy suggest that transverse closure resulted in lower hernia rates than vertical closure. We sought to compare the incidence of incisional hernia after robotic radical prostatectomy after vertical and transverse extraction site closure., Materials and Methods: We conducted a clinically integrated, crossover, cluster randomized trial at a single tertiary referral center (January 2016-September 2021) comparing the rate of hernia after transverse vs vertical extraction site excision in 1356 patients treated with minimally invasive radical prostatectomy. The primary outcome was between-group incidence of incisional hernia within 15 months of prostatectomy defined by physical examination and self-reported patient surveys., Results: Overall, 197 (20%) patients developed an incisional hernia within 15 months, 797 did not have an incisional hernia within this period, and 362 had missing outcome data regarding incisional hernia. We found no significant difference in hernia rates between the 2 incision types (absolute between-group difference 1.8%; 95% CI -3.4%, 6.6%; P = .5) in the primary analysis or in the 3 sensitivity analyses. Notably, because of the inclusive definition of hernia used, these data cannot be used as an estimate of the true prevalence of incisional hernia., Conclusions: Surgeons should choose the incision and closure approach they are most comfortable with when extracting specimens. Studies of modifications to the surgical technique are best conducted as randomized comparisons, and the clinically integrated, crossover, cluster randomized trial allows large trials to be completed at a single center and at low cost., Trial Registration: ClinicalTrials.gov: NCT01407263.

Robotic-assisted laparoscopic prostatectomy (RALP) is the surgical standard of care for patients with localized prostate cancer. Although uncommon, the procedure involves a potential risk of injury to adjacent anatomical structures. We report on a unique case of iatrogenic ureteral injury during RALP that required subsequent robotic-assisted laparoscopic ureteral reimplantation for definitive repair. A 57-year-old male underwent RALP using the Da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA). The procedure was unremarkable and a 20 French Foley catheter was placed with plans for removal after one week following a negative cystogram. On postoperative day two, his creatinine level elevated to 2.69 mg/dL from a baseline of 1.40 mg/dL, left-sided flank pain increased, and non-contrast CT imaging revealed moderate left proximal hydroureteronephrosis and no other abnormalities. Aside from mild nausea on postoperative day one, he had no other symptoms. An integrated stent was unable to be placed by urology at this time. Subsequently, a left percutaneous nephrostomy tube was placed under fluoroscopic guidance. After this intervention, the patient's symptoms improved and the decision was made not to proceed with operative re-exploration at this time to attempt identification of the obstruction. Three weeks later, the patient underwent cystoscopy with attempted left retrograde ureteropyelography and left ureteroscopy due to suspected distal obstruction. This revealed complete obstruction of the intramural portion of the ureter, presumed to be secondary to suture ligation at the time of the vesicourethral anastomosis. Seven weeks postoperatively, the patient underwent robotic-assisted laparoscopic left ureteral reimplantation. Thereafter, the patient had a resolution of his left hydroureteronephrosis and acute kidney injury. This case describes an intravesical ureteral ligation during RALP. An iatrogenic intravesical ureteral ligation has far less guiding literature than a more common ureteral transection. Additionally, ureteral transection is often identified and managed intraoperatively, while the ureteral ligation presented in this case is far less likely to be apparent during surgery. Early identification will allow for rapid reoperation to manage the injury. We hypothesize that during the vesicourethral anastomosis, the left intramural ureter was ligated. Importantly, with the use of a 3-0 V-Loc stitch for the vesicourethral anastomosis, its barbed nature would not facilitate simple surgical removal. In conclusion, when performing RALP, the depth of the bladder-sided vesicourethral anastomotic stitch should be carefully considered to avoid a similar injury., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Baetzhold et al.)

Background/Objectives: The presence of seminal vesicle invasion (SVI) in prostate cancer (PCa) is associated with poorer postoperative outcomes. This study evaluates the predictive value of magnetic resonance imaging (MRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) for SVI in PCa. Methods: This cohort study included consecutive robotic prostatectomy patients for PCa at three Australian tertiary referral centres between April 2016 and September 2022. MRI and PSMA PET/CT results, clinicopathological variables, including age, BMI, prostate-specific antigen (PSA), PSA density, DRE, Biopsy Gleason score, Positive biopsy cores, PIRADS v2.1 score, MRI volume and MRI lesion size were extracted. The sensitivity, specificity, and accuracy of MRI and PSMA PET/CT for predicting SVI were compared with the histopathological results by receiver operating characteristic (ROC) analysis. Subgroup univariate and multivariate analysis was performed. Results: Of the 528 patients identified, 86 had SVI on final pathology. MRI had a low sensitivity of 0.162 (95% CI: 0.088-0.261) and a high specificity of 0.963 (95% CI: 0.940-0.979). The PSMA PET/CT had a low sensitivity of 0.439 (95% CI: 0.294-0591) and a high specificity of 0.933 (95% CI: 0.849-0.969). When MRI and PSMA PET/CT were used in combination, the sensitivity and specificity improved to 0.514 (95%CI: 0.356-0.670) and 0.880 (95% CI: 0.813-0.931). The multivariate regression showed a higher biopsy Gleason score ( p = 0.033), higher PSA ( p < 0.001), older age ( p = 0.001), and right base lesions ( p = 0.003) to be predictors of SVI. Conclusions: MRI and PSMA PET/CT independently underpredicted SVI. The sensitivity and AUC improved when they were used in combination. Multiple clinicopathological factors were associated with SVI on multivariate regression and predictive models incorporating this information may improve oncological outcomes.

In the present study, we aimed to systematically evaluate the current evidence regarding the intraoperative workload of surgeons performing robot-assisted radical prostatectomy (RARP) for prostate cancer. A systematic search was carried out in the PubMed-MEDLINE and Web of Science databases through April 2024 using the following search terms: "workload AND robot assisted radical prostatectomy", "workload AND robotic radical prostatectomy", "task load AND robotic radical prostatectomy", "task load AND robot assisted radical prostatectomy" and "NASA-TLX AND robot assisted radical prostatectomy" by combining population, intervention, comparison, and outcome (PICO) terms, following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We therefore selected studies that included patients with prostate cancer (P) who underwent robotic radical prostatectomy (I) and reported a workload/task load questionnaire (C) to assess the intraoperative workload/task load of the surgeon performing robot-assisted radical prostatectomy (O). A total of 11 studies were identified. The surgeon's workload during RARP was assessed using the National Aeronautics and Space Administration task load index (NASA-TLX) and/or the surgery task load index (SURG-TLX) in the studies. Total NASA-TLX scores of the studies ranged from 22.7 ± 3.2 to 62.0 ± 6.4. Mental and physical demands, flow interruptions, surgeon experience, the use of single or multiple ports, and the relationship between the surgeon and other staff in the operating theater may play a role in the intraoperative workload of the console surgeon. The studies we reviewed suggest that RARP offers an acceptable workload for the console surgeon despite its mental demands., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Prostate cancer is the second most common cancer among men, with many treatment modalities available for patients, such as radical prostatectomy, external beam radiotherapy, brachytherapy, high-intensity focused ultrasound, cryotherapy, electroporation and other whole-gland or focal ablative novel techniques. Unfortunately, up to 60% of men with prostate cancer experience recurrence at 5 to 10 years. Salvage radical prostatectomy can be offered as an option in the setting of recurrence after a primary non-surgical treatment. However, the complexity of salvage radical prostatectomy is considered to be greater than that of primary surgery, making it the least popular treatment of choice. With the wide use of robotic platforms in urologic oncologic surgery, salvage radical prostatectomy has attracted attention again because, compared to past data, modern series involving salvage Robot-Assisted Radical Prostatectomy have shown promising results. In this narrative literature review, we comprehensively examined data on salvage radical prostatectomy. We investigated the correlation between the different types of primary prostate cancer therapy and the following salvage radical prostatectomy. Furthermore, we explored the concept of a robotic approach and its beneficial effect in salvage surgery. Lastly, we emphasized several promising avenues for future research in this field.

Introduction: Retzius-sparing prostatectomy was promoted with the early continence result. The long-term oncologic outcome is still unknown. In this study, we aimed to compare the intermediate-term oncologic outcomes of these two approaches in patients' cohort who were treated as part of a randomized controlled trial. Methods: A total of 120 patients were previously randomized equally to receive Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RS-RARP) vs standard robot-assisted laparoscopic radical prostatectomy (S-RARP) between January 2015 and April 2016. Baseline, surgical, and pathologic characteristics as well as oncologic outcomes were assessed. The analysis was done based on the treatment received. Result: Sixty-three patients underwent S-RARP, whereas 57 patients underwent RS-RARP. There was no statistically significant difference in the baseline nor surgical characteristics. The median follow-up was 71.24 (interquartile range: 59.75-75.75) months. There were more pathologic T3 diseases in RS-RARP. There was no significant difference in the positive margin status nor in the biochemical recurrence (BCR) rate among both groups. After S-RARP and RS-RARP, 6 and 10 patients had BCR, and the 5 years BCR-free survival was 91% and 85%, respectively ( p  = 0.21). Conclusion: In this cohort, there was no difference in BCR in the patients who received either technique. Further multi-institutional studies with a larger sample size and longer follow-up are required.

Objective: The objective was to investigate the current evidence and discern urinary continence rates post robot-assisted laparoscopic radical prostatectomy (RALP)., Methods: A systematic review of the literature was carried out, searching the Embase, Scopus and PubMed databases between 1 January 2000 and 1 May 2020. The search terms "Robotic prostatectomy AND continence" were employed. Articles were selected in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Statistical analysis was performed using the programme R; cumulative analysis of percentage of men continent was calculated., Results: A total of 3101 abstracts and 50 full text articles were assessed, with 22 publications included (n = 2813 patients). There were 21 randomised controlled trials and one partly randomised controlled trial with four publications comparing RALP to other prostate cancer treatments. Thirteen studies explored different RALP techniques, and five studies examined vesicourethral anastomosis (VUA). There were statistically significant improvements in early urinary continence rates in three studies analysing reconstructive techniques (83% vs 60%, p = 0.04; 26.5% vs 15.4%, p = 0.016; 77% vs 44.1%, p ≤ 0.001). Long-term continence rates were not significantly improved across all studies assessing reconstruction. One study comparing RALP vs laparoscopic radical prostatectomy (LRP) demonstrated a statistically significant improvement in continence at 3 months (80% vs 73.3%, p < 0.001); 6 months (83.3% vs 81.4%, p < 0.001); 12 months (95% vs 83.3%, p < 0.001) and 24 months (96.7% vs 85%, p < 0.001). Early continence was less favourable for RALP when compared to brachytherapy (BT) patients at 3 months (86% vs 98.7%, p < 0.05) and 6 months (90.5% vs 98.7%, p < 0.05)., Conclusion: Early continence rates were improved across numerous techniques in RALP. These results were not translated into significantly improved long-term outcomes. Continence rates following RALP were favourable compared to LRP, similar to ORP and less favourable compared to BT. Our findings suggest that post-RALP continence can be further improved with alterations in robotic technique., (© 2024. The Author(s).)

Introduction: Robot-assisted laparoscopic prostatectomy (RALP) and transurethral resection of bladder tumor (TURBT) are two common surgeries for prostate and bladder cancer. We aim to assess the trends in the site of care for RALP and TURBT before and after the COVID outbreak., Materials and Methods: We identified adults who underwent RALP and TURBT within the California Healthcare Cost and Utilization Project State Inpatient Database and the State Ambulatory Surgery Database between 2018 and 2020. Multivariable analysis and spline analysis with a knot at COVID outbreak were performed to investigate the time trend and factors associated with ambulatory RALP and TURBT., Results: Among 17,386 RALPs, 6,774 (39.0%) were ambulatory. Among 25,070 TURBTs, 21,573 (86.0%) were ambulatory. Pre-COVID, 33.5% of RALP and 85.3% and TURBT were ambulatory, which increased to 53.8% and 88.0% post-COVID (both p < 0.001). In multivariable model, RALP and TURBT performed after outbreak in March 2020 were more likely ambulatory (OR 2.31, p < 0.0001; OR 1.25, p < 0.0001). There was an overall increasing trend in use of ambulatory RALP both pre- and post-COVID, with no significant change of trend at the time of outbreak (p = 0.642). TURBT exhibited an increased shift towards ambulatory sites post-COVID (p < 0.0001)., Conclusions: We found a shift towards ambulatory RALP and TURBT following COVID outbreak. There was a large increase in ambulatory RALP post-COVID, but the trend of change was not significantly different pre- and post-COVID - possibly due to a pre-existing trend towards ambulatory RALP which predated the pandemic.

Objectives: To assess the ChatGPT (Open AI) artificial intelligence platform's utility and accuracy as a patient education tool in robotic-assisted radical prostatectomy., Materials and Methods: The ChatGPT 3.5 interface ( https://chat.openai.com/chat ) was interrogated and asked the 14 questions related to the frequency of complications of robotic-assisted radical prostatectomy as listed on British Association of Urological Surgeons (BAUS) patient information leaflet "Robotic-Assisted Laparoscopic Radical Prostatectomy)" published July 2021. The AI's responses to each question were tabulated, and compared alongside the official figures quoted from the BAUS information leaflet. A global assessment of the AI's response was also made for accuracy and relevance to patients., Results: Of the 14 questions asked, 11/14 (78.6%) of ChatGPT's quoted figures were considered concordant and comparable to those quoted by the BAUS patient information leaflet. 13/14 (92.9%) of ChatGPT's responses were globally assessed to contain accurate information, appropriate, and pertinent to a patient's potential enquiry., Conclusion: ChatGPT is a powerful tool and is able to generate accurate and helpful information for patients seeking information regarding urological procedures and their potential complications. It is not, however, infallible, and urologists should remain vigilant in their patient interactions to any potential misinformation a patient may have gathered from it in their personal research prior to surgery., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

New imaging technologies play a pivotal role in the current management of patients with prostate cancer. Robotic assisted radical prostatectomy (RARP) is a standard of care for localized disease and through the already imaging-based console subject of research towards combinations of imaging technologies and RARP as well as their impact on surgical outcomes. Therefore, we aimed to provide a comprehensive analysis of the currently available literature for new imaging technologies for RARP. On 24 January 2023, we performed a systematic review of the current literature on Pubmed, Scopus and Web of Science according to the PRISMA guidelines and Oxford levels of evidence. A total of 46 studies were identified of which 19 studies focus on imaging of the primary tumor, 12 studies on the intraoperative tumor detection of lymph nodes and 15 studies on the training of surgeons. While the feasibility of combined approaches using new imaging technologies including MRI, PSMA-PET CT or intraoperatively applied radioactive and fluorescent dyes has been demonstrated, the prospective confirmation of improvements in surgical outcomes is currently ongoing.

Introduction: Urinary incontinence is one of the most common long term side effects after robotic prostatectomy (RALP), and significantly impacts patient quality of life. Pelvic floor muscle training (PFMT) has been a standard part of the urologist's armamentarium for maximizing continence outcomes post-op. Recently, aerobic and resistance exercises have been described as improving functional outcomes post RALP. We performed a systematic review to determine the influence of exercise, in the form of PFMT, aerobic exercise, and resistance training, on incontinence post-RALP., Materials and Methods: This systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with database searches performed on January 14, 2022 and again on August 10, 2022 to account for any new publications. The search identified 1675 papers. Of the 1675 papers, 1007 were found to be duplicates, leaving 668 total studies for screening. Of the 668 papers, nine met all inclusion criteria. Of the nine, four studies presented data from patients who had undergone RALP and were included in the final descriptive systematic review., Results: Sayilan et al. and Milios et al. showed postoperative PFMT and physical activity resulted in significantly improved continence outcomes at 1 and 6 months and 2, 6, and 12 weeks postoperatively, respectively. Heydenreich et al. combined PFMT with an oscillating rod therapy, which was found to significantly improve both postoperative urinary continence and health related quality of life compared to PFMT and relaxation techniques alone. On the contrary, Goode et al. examined delivery of exercise information and demonstrated no difference in continence outcomes between focused telehealth PFMT program and generic prostate cancer education., Conclusion: Pelvic floor muscle training, with or without adjunct therapies, results in improved continence outcomes post RALP. Supervised training programs may or may not accelerate this finding. There is no recent literature to support or refute the benefit of aerobic exercise or resistance training on reducing post-prostatectomy incontinence after RALP., Competing Interests: None., (AJCEU Copyright © 2023.)

Post-prostatectomy Urinary incontinence (PPUI) due to open or robotic surgery has a negative impact on patients' psycho-social well-being and leads to altered quality of life (Kielb and Dunn in J Urol 166:958-61, 2001). Sphincteric incompetence overall remains the primary cause of PPUI, and it is believed that direct damage and manipulation intraoperatively could be the probable causes [1] (Bayoud et al. in Int J Urol 22:283-7-10, 2015). Pelvic floor muscle (PFM) rehabilitation appears to be beneficial in hastening the return of continence (Kampen and Poppel in Lancet 355:98-102, 2000). Hence, there is a need to re-educate or strengthen the pelvic floor muscles. To study the return of continence, and time duration required for the pelvic floor muscles to regain strength and endurance, thereby, leading to urinary continence and its effect on the quality of life of patients who have undergone robotic prostatectomy. Pelvic floor muscle grading, a 24 h pad test, and an International Prostate symptom scoring (IPSS) were the outcome measures used to assess the effect on incontinence status post-operatively. 69 patients were screened between a duration of 3 years, i.e., 2017-2020. Four patients remained incontinent 3 months post-surgery. On the contrary, 65 patients regained continence. There is a definitive effect of early Kegel's exercise, the patient gains good pelvic floor muscle strength, portraying a reduction in dribbling or leakage of urine. Also, there is an improvement in the quality of life after Robotic Prostatectomy in Prostate cancer patients after 6 weeks of surgery. 94.20% of the patients have shown a have gained continence by 3 months post-robotic prostatectomy following a regular exercise regime of Kegel's exercise., (© 2022. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Robot-assisted radical prostatectomy (RARP) has been a treatment for men who suffer from intermediated to high-risk prostate cancer in Australia since 2003. The primary outcomes in relation to learning curves in robotic surgery have been extensively researched in overseas populations, but there is no study from a cohort of Australian surgeons performing RARP. This study aims to highlight the effect of RARP learning curves on primary surgical outcomes in a high-volume Australian centre., Methods: A retrospective audit of all RARP performed at Epworth Healthcare from 2016 to 2021 was performed. The primary outcome data collected included operating time (OT), estimated blood loss (EBL), and positive surgical margins (PSM). Exclusion criteria were applied. Positive outcomes were set at OT 240 min, blood loss 310 mL, and negative surgical margins., Results: A total of 3969 cases were analysed for a cohort of 53 surgeons. Of these surgeons, 24 surgeons have performed >50 operations to be able to undergo learning curve analysis. The median OT was 229 min, the median blood loss was 353 mL, and most cases had negative surgical margins (>1 mm, n  = 3681, 92.7%). The mean learning curve transition point was 65 cases. There was a significant difference in the EBL and rate of PSM for the higher volume cohort (p = 0.002 and <0.0001, respectively)., Conclusion: We perform a retrospective study of all RARP performed at a high-volume Australian centre. Higher volume surgeons demonstrate that primary outcomes improve with a higher caseload (EBL, PSM). Learning curve transition points for RARP are comparable to international high-volume surgeons. Learning curve data could form the benchmark for RARP training and skills development., Competing Interests: None to declare., (© 2022 Asian Pacific Prostate Society. Publishing services by Elsevier B.V.)

A radical prostatectomy is frequently used as the first-line treatment for men with prostate cancer. Persistent urinary incontinence after surgery is one of the most severe adverse events. We report the results of a comprehensive literature search focused on post-prostatectomy urinary incontinence (PPI), performed by a panel of experts on non-neurogenic lower urinary tract symptoms. The data on the prevalence and timing of PPI are very heterogeneous. The etiology of PPI can be multifactorial and mainly dependent on patient characteristics, lower urinary tract function or surgical issues. The medical history with a physical examination, the use of validated questionnaires with a voiding diary and pad tests are determinants in identifying the contributing factors and choosing the right treatment. Lifestyle intervention and urinary containment are the most frequently used strategies for the conservative management of PPI, while antimuscarinics, beta-3 agonists and duloxetine (off-label) are drugs indicated to manage PPI with a concomitant overactive bladder. Surgical therapies for the management of post-prostatectomy SUI include non-adjustable trans-obturator slings in men with mild-to-moderate incontinence and an artificial urinary sphincter in men with moderate-to-severe incontinence.

Background: Concomitant robotic-assisted laparoscopic prostatectomy (RALP) and robotic inguinal hernia repair (RIHR) has been reported. Nevertheless, data on its safety is lacking and some surgeons avoid performing both operations concurrently due to the potential risk of mesh related complications in the setting of a fresh vesicourethral anastomosis. We aimed to investigate differences in 30-day outcomes between patients undergoing RALP+RIHR and those undergoing RIHR alone., Methods: Patients who have undergone concomitant RALP and RIHR with 30-day follow-up available were identified within the Abdominal Core Health Quality Collaborative. Using a propensity score algorithm, they were matched with a cohort of patients undergoing RIHR alone based on confounders such as body mass index, age, ASA class, smoking, hernia size and recurrent status and prior pelvic operation. The groups were compared for 30-day rates of surgical site infection (SSI), surgical site occurrences (SSO), surgical site occurrences requiring operative intervention (SSOPI) and hernia recurrence., Results: 24 patients underwent RALP + RIHR and were matched to 72 patients who underwent RIHR alone (3:1). Median age was 64 years, 33% were obese and 17% smokers. No significant differences were found on 30-day rates of overall complications (21% RALP + RIHR vs. 15% RIHR, p = 0.53) and surgical site occurrences (12% RALP + RIHR vs.11% RIHR, p = 0.85). No patient in the RALP + RIHR group had a 30-day SSI, SSOPI or early recurrence., Conclusion: RALP+RIHR appears not to result in increased rates of wound complications, overall complications or early recurrence when compared to patient undergoing RIHR alone. Prospective, controlled studies with larger number of patients are needed to confirm our findings., Competing Interests: Declaration of competing interest Sergio Mazzola Poli de Figueiredo, Rui-Min Diana Mao and Sharon Phillips have nothing to disclose. Luciano Tastaldi has received the AHSQC Resident/Fellow Research Grant Award that is related to this work. Richard Lu has received payment for presentations from Intuitive Surgical but not related to this work., (Copyright © 2022. Published by Elsevier Inc.)

Objectives: To prospectively analyse robotically administered transperitoneal transversus abdominis plane (robot-assisted transversus abdominis plane [RTAP]) compared with both ultrasonography-guided transversus abdominis plane (UTAP) and local anaesthesia (LA) with regard to pain control and narcotic use in patients undergoing robot-assisted prostatectomy (RARP) or robot-assisted partial nephrectomy (RAPN)., Subjects/patients and Methods: Patients undergoing RARP or RAPN were randomized in a single-blind 2:2:1 fashion to RTAP:UTAP:LA, with the study powered to evaluate superiority of UTAP to LA and non-inferiority of RTAP to UTAP. We compared time to deliver the block, operating room time, postoperative pain scores using the visual analogue scale, and intra-operative and postoperative analgesia consumption., Results: A total of 143 patients were randomized and received treatment. There was no significant difference in patient baseline characteristics. UTAP did not demonstrate superiority to LA in terms of pain control. RTAP and LA were faster to administer than UTAP (time to perform block 2.5 vs 2.5 vs 6.25 min; P &lt; 0.001). There was no difference in postoperative narcotic, acetaminophen, ketorolac or ondansetron requirements among the three groups (P &gt; 0.05). The study was terminated early due to the unexpected efficacy of LA., Conclusion: This study showed that UTAP and RTAP do not provide superior pain control to LA. The efficiency, effectiveness, and ease of administration of LA make it an excellent option for first-line therapy for postoperative analgesia., (© 2022 BJU International.)

Background: Pathological involvement of the seminal vesicle poses a treatment dilemma following robotic prostatectomy. Margin status plays an important role in deciding further management. A wide range of treatment options are available, including active monitoring, adjuvant radiotherapy, salvage radiotherapy, and occasionally androgen deprivation therapy. Patients undergoing postoperative radiotherapy tend to have higher risk of urinary and bowel morbidities. The recent RADICALS-RT concluded that adjuvant radiotherapy did not have any benefit compared with salvage radiotherapy. We aim to audit the incidence, margin status, and management of T3b cancer cases at our center., Materials and Methods: A retrospective analysis was conducted of all patients diagnosed with pathological T3b (pT3b) prostate cancer following robotic-assisted laparoscopic prostatectomy from January 2012 to July 2020. Preoperative parameters analyzed included prostate-specific antigen (PSA), T stage, and age. A chi-square test and 2-tailed t test were used to determine the relationship between categorical and continuous variables, respectively. Kaplan-Meier survival curves were generated to assess overall survival in patients with pT3b prostate cancer and used to compare unadjusted progression-free survival among those who underwent adjuvant and salvage radiotherapy., Results: A total of 83 (5%) of 1665 patients who underwent robotic prostatectomy were diagnosed with pT3b prostate cancer between January 2012 and July 2020. Among these, 36 patients (44%) did not receive any radiotherapy during follow-up, compared with 26 patients (31%) who received adjuvant radiotherapy and 21 (25%) who received salvage radiotherapy. The median age of our cohort was 64 (SD, 6.4) years. Mean PSA at presentation was 12.7 μg/L. Positive margins were seen in 36 patients (43%); however, there was no statistically significant difference between treatment groups ( p = 0.49). The median overall survival was 96%. There was no significant difference between the adjuvant and salvage groups in terms of biochemical progression-free survival ( p = 0.66). Five-year biochemical progression-free survival was 94% for those in the adjuvant radiotherapy group and 97% for those in the salvage radiotherapy group., Conclusions: Our audit corroborates with the recently concluded RADICALS-RT study, although we had fewer patients with positive margins. Radiotherapy can be avoided in patients with T3b prostate cancer, even if margin is positive, until there is definitive evidence of PSA recurrence. In keeping with the conclusion of RADICALS-RT, salvage radiotherapy may be preferable to adjuvant radiotherapy., Competing Interests: No conflict of interest has been declared by the authors.

Robot-assisted radical prostatectomy (RARP) is the most adopted treatment for localized prostate cancer. The aim of this study was to explore the learning curves (LC) for overall and site-specific positive surgical margins (PSM) occurrence after RARP of multiple surgeons within a step-structured mentor-initiated training program. The study included consecutive patients undergoing RARP between January 2013 and March 2020, by three surgeons: a mentor and his two trainees. Prospectively collected patients' data were retrospectively analyzed. The cumulative summation (CUSUM) method was used to generate the LCs, with turning points indicating the number of cases to reach proficiency levels. Furthermore, the association between PSM and surgical experience was evaluated, adjusting for case mix. A total of 761 consecutive patients were included, 370 treated by the Mentor surgeon, 247 and 144 treated, respectively, by the two Trainees. Mentor and Trainees had similar PSM rates (31.6% vs 28.0% vs 31.3%, p = 0.6). CUSUM charts showed different LC shapes for different PSM locations (postero-lateral, bladder neck, apex, and multifocal/> 3 mm). Surgical experience was significantly associated with overall, postero-lateral, and multifocal/> 3 mm PSMs, in the Mentor series only. Trainees reached their turning points after far fewer cases then the Mentor, both for overall (12 and 31 vs 153), postero-lateral (24 and 30 vs 120), and multifocal/> 3 mm PSMs (9 and 31 vs 153). The achievement of stable SM proficiency takes involved different LCs depending on the prostatic location being considered. Monitoring site-specific LC can indicate the surgical steps for which there may be still room for further technical refinements, even when an apparent proficiency status seems achieved., (© 2022. The Author(s).)

Purpose: Robotic prostatectomy is the most common surgical approach for treating prostate cancer. Patients undergoing robotic prostatectomy may have bullae, which may rupture leading to pneumothorax. We evaluated the incidence of pneumothorax due to preoperative bullae rupture in robotic prostatectomy., Methods: A large retrospective study of patients who underwent robotic prostatectomy between 2009 and 2021 was conducted. Bullae were detected using chest computed tomography. Pneumothorax was detected using a chest X-ray. The primary outcome was the incidence of pneumothorax due to bullae rupture. Secondary outcomes were the prevalence of preoperative bullae and the evaluation of postoperative outcomes, including length of hospital stay, intensive care unit admission rate, and prolonged intensive care unit stay (> 2 days)., Results: A total of 6605 patients were included. The prevalence of preoperative bullae was 3.0% (196/6,605). There was no incidence of pneumothorax due to bullae rupture. No significant difference in the incidences of pneumothorax between patients with and without bullae (0/196 vs. 2/6,409, P > 0.999) was observed. In addition, length of hospital stay, intensive care unit admission rate, and prolonged intensive care unit stay were not significantly different between the two groups. Kaplan-Meier analysis showed that there was no significant difference in lengths of hospital stay between the two groups (log-rank test, P > 0.999)., Conclusion: In our cohort, there was no incidence of pneumothorax following robotic prostatectomy in patients with preoperative bullae. This result could help in the management of patients with prostate cancer with bullae., (© 2022. The Author(s) under exclusive licence to Japanese Society of Anesthesiologists.)

Background: To date, robotic surgery in urology is well established all over the world. The newest platform on the market is the HUGO™ RAS system, developed by Medtronic. In this paper we provide a brief description of the system and describe our system set-up and surgical approach with this new platform in our initial experience of robotic radical prostatectomy (RARP) series., Materials and Methods: After an official training, seven consecutive patients affected by localized prostate cancer underwent RARP with HUGO TM RAS system at our Institution. A description of our surgical approach and docking setup is provided. Docking and console times were reported for all precedures together with main suggestions to facilitate the use of this new system at the beginning of the experience., Results: Our operating room setup has shown to be safe, effective, and easy replicable. During our series, operative times appeared to be easy reproducible and comparable to those obtained with daVinci system. No major system faults and conflicts between robotic arms were observed after the first procedure., Conclusions: Our surgical approach and system configuration for performing RARP with the new HUGO™ RAS system appears to be safe, efficient and easy reproducible.

Background: Radical prostatectomy is considered the gold-standard treatment for patients with localized prostate cancer. The literature suggests there is no difference in oncological and functional outcomes between robotic-assisted radical prostatectomy (RARP) and open (RRP). (2) Methods: The aim of this study was to compare continence recovery rates after RARP and RRP measured with 24 h pad weights and the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF). After matching the population (1:1), 482 met the inclusion criteria, 241 patients per group. Continent patients with a 24 h pad test showing <20 g of urinary leakage were considered, despite severe incontinence, and categorized as having >200 g of urinary leakage. (3) Results: There was no difference between preoperative data. As for urinary continence (UC) and incontinence (UI) rates, RARP performed significantly better than RRP based on objective and subjective results at all evaluations. Univariable and multivariable Cox Regression Analysis pointed out that the only significant predictors of continence rates were the bilateral nerve sparing technique (1.25 (CI 1.02,1.54), p = 0.03) and the robotic surgical approach (1.42 (CI 1.18,1.69) p ≤ 0.001). (4) Conclusions: The literature reports different incidences of UC depending on assessment and definition of continence “without pads” or “social continence” based on number of used pads per day. In this, our first evaluation, the advantage of objective measurement through the weight of the 24 h and subjective measurement with the ICIQ-SF questionnaire best demonstrates the difference between the two surgical techniques by enhancing the use of robotic surgery over traditional surgery.

Background: We performed a retrospective comparison of surgical, oncologic, and functional outcomes after robot-assisted radical prostatectomy between patients who have undergone prior transurethral resection of prostate (TURP) to TURP-naive patients. Methods: Past robotic prostatectomy hospital data were scrutinized to form two matched groups of patients: those who have undergone prior TURP and TURP-naive patients. The perioperative and pathologic data along with functional and oncologic outcomes for a period of 3 years were compared between groups. Results: Compared with TURP-naive patients, prior TURP patients experienced longer robot-assisted laparoscopic prostatectomy times ( p  < 0.001), increased incidence of bladder neck reconstruction ( p  = 0.03), greater blood loss ( p  = 0.0001), and lesser nerve sparing ( p  < 0.01). Complication rates ( p  = 0.3), positive surgical margin ( p  = 0.4), extracapsular disease ( p  = 0.3), or seminal vesicle invasion ( p  = 0.1) were comparable between groups. Continence ( p  = 0.5) and potency ( p  = 0.1) at 1 year were not different between groups. Biochemical recurrence rates were not different at 3 years ( p  = 0.9). Diabetes slowed recovery of continence in patients with prior TURP compared with TURP-naive patients until 6 months after surgery. Conclusion: Although prior TURP makes subsequent robotic prostatectomy more technically demanding, it can be safely performed by experienced surgeons without compromising long-term functional or oncologic outcomes.

Background: Robotic radical prostatectomy (RARP) is a first-line curative treatment option for localized prostate cancer. Postoperative erectile dysfunction and urinary incontinence are common associated adverse side effects that can negatively impact patients' quality of life. Preserving the lateral neurovascular bundles (NS) during RARP improves functional outcomes. However, selecting men for NS may be difficult when there is concern about incurring in positive surgical margin (PSM) which in turn risks adverse oncological outcomes. The NeuroSAFE technique (intra-operative frozen section examination of the neurovascular structure adjacent prostate margin) can provide real-time pathological consult to promote optimal NS whilst avoiding PSM., Methods: NeuroSAFE PROOF is a single-blinded, multi-centre, randomised controlled trial (RCT) in which men are randomly allocated 1:1 to either NeuroSAFE RARP or standard RARP. Men electing for RARP as primary treatment, who are continent and have good baseline erectile function (EF), defined by International Index of Erectile Function (IIEF-5) score > 21, are eligible. NS in the intervention arm is guided by the NeuroSAFE technique. NS in the standard arm is based on standard of care, i.e. a pre-operative image-based planning meeting, patient-specific clinical information, and digital rectal examination. The primary outcome is assessment of EF at 12 months. The primary endpoint is the proportion of men who achieve IIEF-5 score ≥ 21. A sample size of 404 was calculated to give a power of 90% to detect a difference of 14% between groups based on a feasibility study. Oncological outcomes are continuously monitored by an independent Data Monitoring Committee. Key secondary outcomes include urinary continence at 3 months assessed by the international consultation on incontinence questionnaire, rate of biochemical recurrence, EF recovery at 24 months, and difference in quality of life., Discussion: NeuroSAFE PROOF is the first RCT of intra-operative frozen section during radical prostatectomy in the world. It is properly powered to evaluate a difference in the recovery of EF for men undergoing RARP assessed by patient-reported outcome measures. It will provide evidence to guide the use of the NeuroSAFE technique around the world., Trial Registration: NCT03317990 (23 October 2017). Regional Ethics Committee; reference 17/LO/1978., (© 2022. The Author(s).)

The purpose of the study is to evaluate the impact of a multimodal Enhanced Recovery After Surgery (ERAS) protocol on perioperative opioid consumption and hospital length of stay (LOS) after robotic-assisted radical prostatectomy (RARP). We compared the first 176 patients enrolled in the protocol (ERAS group) with the previous 176 patients (non-ERAS group) at a single quaternary institution from December 2017 to June 2019. The ERAS protocol included a multimodal opioid-sparing regimen utilizing acetaminophen, gabapentin, celecoxib, and liposomal bupivacaine. Demographic data, co-morbidities, post-operative pain scores, post-operative opiate consumption measured by morphine milligram equivalents (MME), operating time, and LOS were collected. The two groups were compared using chi-squared, Fisher exact, or Student t tests as appropriate. Multivariable logistic regression analysis was performed to identify predictors of prolonged LOS (> 1 day). The ERAS and non-ERAS groups were equivalent in terms of baseline characteristics and pathological data. The ERAS group had lower post-operative pain scores, post-operative opiate consumption (MME 15 vs. 46, p < 0.01), and LOS (1.2 vs. 1.7 days, p < 0.01) compared to the non-ERAS group. Only 22% in the ERAS cohort had a prolonged LOS compared to 39% of the non-ERAS group (p < 0.01). The ERAS protocol was a negative predictor of prolonged LOS on multivariable logistic regression analysis (odds ratio 0.39, 95% confidence interval 0.22-0.70, p < 0.01). A limitation of this study is its single-center retrospective design. The implementation of a multimodal opioid-sparing ERAS protocol was associated with improved pain control, reduced perioperative opioid usage, and shorter LOS after RARP., (© 2021. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Purpose: This study intended to assess the safety and feasibility of performing concurrent robotic-assisted laparoscopic prostatectomy (RALP) and robotic inguinal hernia repair (RIHR)., Method: We systematically searched the PubMed, Embase and Cochrane Library database up to the year 2020 to identify studies that assessed patients who underwent RALP and RIHR in the same settings., Results: Thirteen studies were considered suitable for a systematic review and seven for Meta-analysis. RALP and RIHR were associated with significantly longer operative time. RIHR added on average 26 min to the operation time (8, 45 95% CI, p  = 0.005, I 2 97%). Concurrent RALP and RIHR was not associated with a higher incidence of blood loss (-13, 6 95% CI, p  = 0.43, I 2 18%), length of stay (-0.08, 0.06 95% CI, p  = 0.73, I 2 0%) or early postoperative complications., Conclusion: Concurrent robotic repair of an inguinal hernia during RALP appears feasible and safe. Urologists should be encouraged to repair hernias encountered during RALP keeping in mind possible complications including wound infection, mesh infection, chronic inguinal pain and recurrence of hernia.

Background: To determine safety and feasibility of single-port Retzius-sparing robot-assisted radical prostatectomy (SP-rsRARP) using the da Vinci ® SP (Intuitive Surgical, Sunnyvale, CA) robotic platform in men with adenocarcinoma of the prostate. Patients and Methods: Twenty-eight consecutive men with prostate cancer underwent SP-rsRARP by one of two surgeons (J.B., S.C.). Data for perioperative, pathologic, and functional outcomes were collected prospectively and retrospectively analyzed. Results: Mean (standard deviation) follow-up was 6 (3) months. Mean age was 65.3 years old with an average body mass index of 25.2 kg/m 2 . Mean preoperative prostate-specific antigen (PSA) was 10.2 ng/mL. Average prostate weight was 42 g. Three patients (11%) had prior radiation to the prostate. There were no intraoperative complications or conversions of technique. Lymphadenectomy was performed in 24 (86%) patients and nerve sparing in 14 (46%) patients. Mean operative time (skin to skin) was 234 minutes with an average estimated blood loss of 148 mL. Length of hospital stay averaged 23 hours. Seventeen (61%) of the patients did not require opioids for postoperative pain. Two Clavien Grade IIIa complications occurred (lymphocele aspiration and dilation of bladder neck contracture). Pathologic grade group was group 1 (0%), group 2 (57%), group 3 (29%), and group 4-5 (14%). Pathologic stage was T2 (15/28, 54%) and T3a,b (13/28, 46%). Five patients (18%) had a positive surgical margin, four (80%) of whom had T3 disease. One patient (4%) had a detectable PSA during follow-up and opted for adjuvant radiation. Twenty-three patients (82%) were continent at foley removal. Postoperative mean sexual health inventory for men score in those who underwent nerve sparing was 18 at 3 months follow-up. Conclusions: SP-rsRARP appears safe and feasible. Early continence rates are promising. Full characterization of outcomes requires longer follow-up and larger cohort validation.

Several benefits have been reported after applying the principles of enhanced recovery after surgery (ERAS) into the perioperative care of patients undergoing robot-assisted radical prostatectomy (RARP). Nevertheless, there are still barriers. We aimed to identify the key areas by systematically surveying urology departments in Germany and Austria. A 27-question survey on the adoption of ERAS principles for the perioperative care of RARP patients was designed, in compliance with the guidelines on good practice in conducting and reporting of survey research. After positive testing for face and content validity, the survey was distributed via postal mail to 82 departments performing RARP. In total, 39 departments responded to our survey (response rate 48%). The ERAS adoption rates ranged from 21 to 97%, with nine ERAS principles being widely adopted (72-92% of the departments). The lowest adoption rates and, subsequently, the largest potential for optimization were detected for the preoperative nutrition counselling (21%), preoperative pelvic floor physiotherapy (54%), postoperative early initiation of nutrition (44%) and postoperative patient audit for further quality improvement (36%). High-volume centers performed more frequently a perioperative nutrition counselling (8/27; 30%) than low-volume centers (0/12; 0%; p = 0.036). The implementation of the ERAS principles into the perioperative care algorithm were medium-to-high, yet not optimal. Our real-world data assessment revealed four key areas showing low adoption rates (nutrition counselling, preoperative pelvic floor physiotherapy, early initiation of nutrition and patient audit), implying a great potential for further optimization., (© 2021. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Introduction: Robotic prostatectomy requires pneumoperitoneum and a steep Trendelenburg position; however, this condition may compromise cerebral blood flow. Here, we evaluated the effect of pneumoperitoneum and the steep Trendelenburg position on internal carotid artery (ICA) blood flow measured by Doppler ultrasound during robotic prostatectomy., Methods: Patients who underwent robotic prostatectomy were prospectively recruited. The ICA blood flow was measured at the following five time-points: with the patient awake and in the supine position (Ta), 10 min after anaesthetic induction in the supine position (T1), 10 (T2) and 30 (T3) min after pneumoperitoneum in the steep Trendelenburg position, and at the end of surgery in the supine position after desufflation of the pneumoperitoneum (T4). Hemodynamic and cerebrovascular variables were measured at each time-point., Results: A total of 28 patients were evaluated. The ICA blood flows were significantly lower at T2 and T3 than at T1 (162.3 ± 44.7 [T2] vs. 188.0 ± 49.6 ml/min [T1]; p = .002, 163.1 ± 39.9 [T3] vs. 188.0 ± 49.6 ml/min [T1]; p = .009). The ICA blood flow also differed significantly between Ta and T1 (236.8 ± 58.3 vs. 188.0 ± 49.6 ml/min; p < .001). Heart rates, cardiac indexes, peak systolic velocity, and end-diastolic velocity were significantly lower at T2 and T3 than at T1. However, ICA diameter, mean blood pressure, and end-tidal carbon dioxide partial pressure did not differ significantly at all time-points., Conclusion: Pneumoperitoneum and the steep Trendelenburg position caused decreased ICA blood flow, suggesting that they should be carefully performed during robotic prostatectomy, especially in patients at risk of postoperative cerebrovascular accident., (© 2022 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.)

Introduction: To evaluate the use of preoperative magnetic resonance imaging (MRI) as a predictor of positive margins after radical prostatectomy (RP). This is important as such patients may benefit from postoperative radiotherapy. With the advent of preoperative MRI, we posited that pelvimetry could predict positive margins after RP in patients with less-than ideal pelvic dimensions undergoing robotic-assisted laparoscopic surgery., Materials and Methods: After IRB approval, data from patients undergoing RP at our center between 1/1/2018 and 12/31/2019 (n = 314) who had undergone prior prostate MRI imaging (n = 102) were analyzed. All RPs were performed using robotic-assisted laparoscopic technique. Data from the cancer center data warehouse were retrieved, to include postoperative T-stage, gland size, responsible surgeon, PSA, patient body mass index, and surgical margin status. These data were analyzed with corresponding pelvimetry data from 91 preoperative scans with complete data and imaging., Results: On multivariable analysis, pathologic T-stage (p = 0.004), anteroposterior pelvic outlet (p = 0.015) and pelvic depth (length of the pubic symphysis; p = 0.019) were all statistically correlated with positive surgical margins., Conclusions: With the widespread use of MRI in the initial staging of prostate cancer, automated radiomic analysis could augment the critical data already being accumulated in terms of seminal vesical involvement, extracapsular extension, and suspicious lymph nodes as risk factors for postoperative salvage radiation. Such automated data could help screen patients preoperatively for robotic RP.

Background: Decisional conflict and post-treatment decisional regret have been documented in men with localised prostate cancer (LPC). However, there is limited evidence regarding decisional outcomes associated with the choice between robotic-assisted radical prostatectomy (RARP) and radiotherapy, when both treatment options are available in the public health system. There is increasing support for multidisciplinary approaches to guide men with LPC in their decision-making process. This study assessed decisional outcomes in men deciding between RARP or radiotherapy treatment before and after attending a LPC combined clinic (CC)., Methods: Quantitative longitudinal data were collected from 52 men who attended a LPC CC, where they saw both a urologist and radiation oncologist. Patients completed questionnaires assessing involvement in decision-making, decisional conflict, satisfaction and regret before and after the CC, three months, six months and 12 months post-treatment. Urologists and radiation oncologists also reported their perceptions regarding patients' suitability for, openness to, perceived preferences and appropriateness for each treatment. Data was analysed using paired/independent samples t-tests and McNemar's tests., Results: Most participants (n = 37, 71%) opted for RARP over radiotherapy (n = 14, 27%); one participant deferred treatment (2%). Urologists and radiation oncologists reported low agreement (κ = 0.26) regarding the most appropriate treatment for each patient. Participants reported a desire for high levels of control over their decision-making process (77.5% patient-led, 22.5% shared) and high levels of decisional satisfaction (M = 4.4, SD = 0.47) after the CC. Decisional conflict levels were significantly reduced (baseline: M = 29.3, SD = 16.9, post-CC: M = 16.3, SD = 11.5; t = 5.37, P < 0.001) after the CC. Mean decisional regret scores were 'mild' at three-months (M = 16.0, SD = 17.5), six-months (M = 18.8, SD = 18.7) and 12-months (M = 18.2, SD = 15.1) post-treatment completion., Conclusion: This is the first Australian study to assess decisional outcomes when patients are offered the choice between RARP and radiotherapy in the public health system. A CC seems to support decision-making in men with LPC and positively impact some decisional outcomes. However, larger-scale controlled studies are needed to confirm these findings., Competing Interests: Conflict of interest They were not involved in the collection or analysis of patient data., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The incidence of bladder neck contracture (BNC), or postprostatectomy vesicourethral anastomosis, has declined since the advent of robotic surgery. However, men with peripheral vascular comorbidities, among other factors, still have a high risk of developing this complication after any surgery that involves manipulation of the prostate. The best strategy for BNC management remains uncertain because of inconsistency in success for different approaches across studies. We reviewed the available evidence on BNC, including the results for endoscopic treatments, scar modulation therapies, and open and robotic bladder neck reconstruction. On the basis of these data, we propose a management flowchart. Patient baseline status and subjective goals and preferences remain crucial in management choices. PATIENT SUMMARY: Contracture of the bladder neck can occur as a complication after surgery to the prostate. We reviewed the evidence for various treatment approaches and propose a flowchart for management of this condition., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: This study aims to compare perioperative and oncologic outcomes between matched cohorts of localized prostate cancer (PCa) operated on by the same surgeon using the da Vinci Si robot and the Revo-i robot. Materials and Methods: Nonmetastatic PCa patients undergoing Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RS-RARP) from January 2016 to December 2020 were matched one-to-one (33:33) to da Vinci Si controls using propensity score matching according to the following covariates: age, American Society of Anesthesiology (ASA) score, body mass index, previous abdominal and endoscopic surgery, preoperative prostate specific antigen, prostate volume, Gleason grade group, tumor stage, and need for pelvic lymphadenectomy. Outcomes of interest were estimated blood loss, length of stay, complication rate, operative times, positive surgical margins, and biochemical recurrence at 6 months. Results: Both cohorts were similar in estimated blood loss, rate of margin positivity, and rate of complications. Length of stay was significantly shorter with the Revo-i cohort. The da Vinci robot showed faster console, suture, and total operation times. Positive margin rate and biochemical recurrence at 6 months were similar in both groups. Conclusion: Despite the longer suture, console, and operative time those in the da Vinci robot in the authors' institution, the Revo-i robot-assisted radical prostatectomy had equivalent short-term oncologic outcomes with the da Vinci standard.

Background: During robotic-assisted radical prostatectomy (RARP), the use of electrocautery near the neurovascular bundles (NVBs) frequently results in thermal injury to the cavernous nerves. The cut and "touch" monopolar cautery technique has been suggested to reduce desiccating thermal injury caused by bipolar energy when vessels are sealed., Objective: To compare potency outcomes between an athermal technique (AT) and touch cautery (TC) to transect the prostatic vascular pedicles (PVPs) and dissect the NVBs., Design, Setting, and Participants: A retrospective concomitant nonrandomized study of AT versus TC was performed in 733 men. A total of 323 undergoing AT had "thin" pedicles, easily suitable for suture ligation. TC was based on "thick" pedicles (n = 230) difficult to suture ligate. Men were excluded for an International Index of Erectile Function (IIEF-5) score of <15 or adjuvant therapies (n = 180)., Surgical Procedure: Single-surgeon RARP., Measurements: Patient-reported outcomes with erectile function (EF) recovery defined as two affirmative answers to erections sufficient for intercourse (ESI; "are erections firm enough for penetration?" and "are the erections satisfactory?"), IIEF-5 scores 15-25, and a novel percent fullness score comparing pre- versus postoperative erection fullness. Logistic regression models assessed the correlation between cautery technique, covariates, and EF recovery., Results and Limitations: In an unadjusted analysis, preoperative IIEF-5, age, body mass index (BMI), and prostate weight were significant predictors of potency recovery. Follow-up was similar (AT 52.7 mo vs TC 54.6 mo, p = 0.534). In logistic regression, preoperative IIEF-5, age, and BMI were significant predictors of EF recovery, defined as IIEF-5 scores 15-25, ESI, and percent fullness >75%. Results were similar when IIEF-5 and percent fullness were assessed continuously., Conclusions: During transection of the PVPs and dissection of the NVBs, TC did not impact EF recovery significantly, compared with an AT., Patient Summary: Electrocautery can be applied safely, with similar outcomes to those of an athermal technique., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Single-port robotic-assisted radical prostatectomy has been reported as a safe and feasible technique. However, recent studies comparing single-port versus multiple-port robotic radical prostatectomy have displayed conflicting results., Objectives: To investigate the benefit of single-port robotic radical prostatectomy and the impact on outcome compared to multiple-port robotic radical prostatectomy., Methods: Based on PRISMA and AMSTAR criteria, a systematic review and meta-analysis were carried out. Finally, we considered the controlled studies with two cohorts (one cohort for single-port RARP and the other cohort for multiple-port RARP). For statistical analysis, Review Manager (RevMan) software version 5.4 was used. The Newcastle-Ottawa Scale was employed to assess the risk of bias., Results: Five non-randomized controlled studies with 666 patients were included. Single-port robotic radical prostatectomy was associated with shorter hospital stays. Only 60.6% of single-port patients (109/180) required analgesia compared to 90% (224/249) of multiple-port patients (Z = 3.50; p = 0.0005; 95% CI 0.07:0.47). Opioid administration was also significantly lower in single-port patients, 26.2% (34/130) vs. 56.6% (77/136) (Z = 4.90; p < 0.00001; 95% CI 0.15:-0.44) There was no significant difference in operative time, blood loss, complication rate, positive surgical margin rate, or continence at day 90., Conclusion: The available data on single-port robotic radical prostatectomy is very limited. However, it seems comparable to the multiple-port platform in terms of short-term outcomes when performed with expert surgeons. Single-port prostatectomies might provide a shorter hospital stay and a lower requirement for opioids; however, randomized trials with long-term follow-up are mandatory for valid comparisons.

Background: Robotic prostatectomy is a costly new technology, but the costs may be offset by changes in treatment patterns. The net effect of this technology on Medicaid spending has not been assessed., Objective: To identify the association of the local availability of robotic surgical technology with choice of initial treatment for prostate cancer and total prostate cancer-related treatment costs., Design and Participants: This cohort study used New York State Medicaid data to examine the experience of 9564 Medicaid beneficiaries 40-64 years old who received a prostate biopsy between 2008 and 2017 and were diagnosed with prostate cancer. The local availability of robotic surgical technology was measured as distance from zip code centroids of patient's residence to the nearest hospital with a robot and the annual number of robotic prostatectomies performed in the Hospital Referral Region., Main Measures: Multivariate linear models were used to relate regional access to robots to the choice of initial therapy and prostate cancer treatment costs during the year after diagnosis., Key Results: The mean age of the sample of 9564 men was 58 years; 30% of the sample were White, 26% were Black, and 22% were Hispanic. Doubling the distance to the nearest hospital with a robot was associated with a reduction in robotic surgery rates of 3.7 percentage points and an increase in the rate of use of radiation therapy of 5.2 percentage points. Increasing the annual number of robotic surgeries performed in a region by 10 was associated with a decrease in the probability of undergoing radiation therapy of 0.6 percentage point and a $434 reduction in total prostate cancer-related costs per Medicaid patient., Conclusions: A full accounting of the costs of a new technology will depend on when it is used and the payment rate for its use relative to payment rates for substitutes., (© 2021. Society of General Internal Medicine.)

Early urinary incontinence remains a major source of morbidity for patients undergoing robotic prostatectomy. The purpose of the study was to determine whether the introduction of a suspension stitch would improve early urinary continence rates in patients undergoing robotic prostatectomy for localized prostate cancer at our department. We retrospectively reviewed patients undergoing robotic prostatectomy with either suspension (n = 119) or figure-of-eight (n = 48) stitching of the dorsal venous complex. The patients submitted EPIC-26 questionnaires before surgery and after 3 and 18 months, respectively. Logistic regression analysis was run to determine the effect of the suspension stitch, nerve-sparing, posterior reconstruction, prostate volume, age and body mass index on early continence rate. The odds ratio of experiencing urinary leaks was 2.1 times higher (95% CI 1.0-4.3) in the figure-of-eight stitch group compared to the suspension stitch group 3 months after surgery (p < 0.05). The early urinary continence rate was 61.3% in the suspension stitch group compared to 35.4% in the figure-of-eight stitch group (p < 0.005). There were no differences between the groups 18 months post-prostatectomy (90.7% in the suspension stitch group versus 81.4% in the non-suspension stitch group, p = 0.1). Ordinal regression analysis identified the suspension stitch, bilateral nerve-sparing and body mass index as independent predictors of urinary continence at 3 months. The association between urinary continence and either unilateral nerve-sparing, posterior reconstruction, prostate volume or age did not reach statistical significance. Our results suggest that the suspension stitch improved early urinary continence following robotic prostatectomy., (© 2020. The Author(s).)

The aim of this paper is to describe our surgical technique and results of proper 6-branch autologous sling tensioning during RALP employing intraoperatively the Retrograde Perfusion Sphincterometry (RPS). Between May 2016 and February 2020, 374 patients underwent RALP with the 6-branch suburethral autologous sling tensioned under intraoperative guidance of RPS. Surgical procedure: Retrograde Leak Point pressure (RLPP) was evaluated by means of RPS after pneumoperitoneum induction (RLPPp), after urethrovescical anastomosis (RLPPa) and during proper sling tensioning (RLPPs). The goal of the sling tensioning was to obtain at the end of the procedure similar pressures as after pneumoperitoneum induction (RLPPs ≅ RLPPp). Intraoperative variables, postoperative complications, and continence recovery outcomes were assessed. A descriptive statistical analysis was performed. Sling positioning and tensioning was feasible in all patients. Mean operative time was 215 min. Proper sling tensioning allowed for the possibility to restore sphincteric efficacy to preoperative value (RLPPs vs. RLPPp (42.5 vs. 42.6) cmH2O). Urinary continence was achieved, respectively, in 58%, 67%, 74%, 88% and 92% of patients after 24 h, 10 days, 1 month, 6 months and 1 year after catheter removal. In conclusion, RPS revealed a valid option for proper autologous 6-branch sling tensioning during RALP, offering the possibility to restore sphincteric apparatus efficiency to its preoperative status to improve EUC., (© 2020. Springer-Verlag London Ltd., part of Springer Nature.)

Robot-assisted laparoscopic radical prostatectomy (RALP) has become the standard of surgical care in the USA and around the world. Over the past 18 years, we have performed 13,000 radical prostatectomies, and our surgical technique has evolved over time. We discuss this evolution and how it has helped us achieve optimal patient outcomes., (© 2020. Springer-Verlag London Ltd., part of Springer Nature.)

Background: Suction during robotic surgery has traditionally been performed by a bedside assistant. Adequately skilled assistants are not always available. We assessed a purpose-designed robotic surgeon-controlled suction catheter for efficiency and safety by comparing with historic cases of suction controlled by a dedicated bedside assistant using standard rigid laparoscopic suction. Methods: Beginning in February 2019, the remotely operated suction irrigation (ROSI) device was used in all robotic prostatectomy procedures, which is a flexible suction catheter manipulated by the surgeon such that a bedside assistant is never required for suction. The initial 300 consecutive cases performed with ROSI were compared with the 300 immediately previous procedures using bedside assistant suction (BAS). Results: There were no statistically significant differences between groups in age, body mass index, American Anesthesiologist Association score, prostate specific antigen, or pathologic stage. Lymph node dissection was performed in all 600 patients. All 300 ROSI cases were completed without requiring switching to BAS. Estimated blood loss (102.7 vs 120.2 mL, p  = 0.001) and operative time (156.1 vs 149.3 minutes, p  < 0.001) were slightly lower in the ROSI group. There was no statistical difference in the 90-day complication rate (Clavien ≥III) between groups, with both having 3% of patients readmitted or seen in the emergency department within 90 days of surgery. Conclusion: Surgeon-controlled suction allowed more surgeon autonomy without a negative impact on efficiency or safety issues requiring "bailout" suctioning by the bedside assistant whether urgent or otherwise. Robotic surgeons without access to skilled bedside assistants should consider suctioning for themselves not unlike the norm for many laparoscopic surgeons.

Objectives: To assess the effects of Retzius-sparing (RS) robotic-assisted laparoscopic prostatectomy (RALP) compared to standard RALP for the treatment of clinically localized prostate cancer., Methods: We performed a systematic search of multiple databases and the grey literature with no restrictions on the language of publication or publication status, up until June 2020. We included randomized controlled trials (RCTs) comparing RS-RALP with standard RALP. We performed a meta-analysis using a random-effect model. The quality of evidence was assessed on an outcome basis according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach., Results: Our search identified six records of five unique RCTs, of which two were published studies, one was in press, and two were abstract proceedings. There were 571 randomized participants, of whom 502 completed the trials. The mean age of participants was 64.6 years and the mean prostate-specific antigen level was 6.9 ng/mL. Approximately 54.2% of participants had cT1c disease, 38.6% had cT2a-b disease, and 7.1% had cT2c disease. RS-RALP probably improves continence within 1 week after catheter removal (risk ratio [RR] 1.74, 95% confidence interval [CI] 1.41-2.14; I 2 = 0%; studies = 4; participants = 410; moderate-certainty evidence). Assuming 335 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 248 more men per 1000 (137 more to 382 more) reporting continence recovery. RS-RALP may increase continence at 3 months after surgery compared to standard RALP (RR 1.33, 95% CI 1.06-1.68; I 2 = 86%; studies = 5; participants = 526; low-certainty evidence). Assuming 750 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 224 more men per 1000 (41 more to 462 more) reporting continence recovery. We are very uncertain about the effects of RS-RALP on serious adverse events compared to standard RALP (RR 1.40, 95% CI 0.47-4.17; studies = 2; participants = 230; very low-certainty evidence)., Conclusions: The findings of this review indicate that RS-RALP may result in better continence outcomes than standard RALP up to 6 months after surgery. Continence outcomes at 12 months may be similar. The disadvantages of RS-RALP may be higher positive surgical margin rates. We are very uncertain about the effect on biochemical recurrence-free survival and potency outcomes. Longer-term oncological and functional outcomes are lacking, and no preplanned subgroup analyses could be performed to explore the observed heterogeneity. Surgeons should discuss these trade-offs and the limitations of the evidence with their patients when considering this approach., (© 2021 The Authors BJU International © 2021 BJU International.)

Background: To evaluate intraoperative and postoperative cytokines in patients who underwent robotic prostatectomy (RP) at a pressure of 12 or 15 mm Hg, and the risk of postoperative ileus., Materials and Methods: We presented the first series evaluating intraoperative and postoperative cytokines in patients undergoing RP at a pressure of 12 or 15 mm Hg by a single surgeon. Changes in cytokine concentrations were shown to correlate with surgical outcomes and pathological states. The study investigated the changes in cytokine concentrations (interferon-γ, tumor necrosis factor-α, interleukin-1β [IL-1β], IL-2, IL-4, IL-6, IL-12, and IL-17) at different pneumoperitoneum pressures and their potential role in the development of postoperative ileus., Results: The data on 10 consecutive patients confirmed that a lower pneumoperitoneum pressure was associated with lower cytokine levels and a lower risk of ileus. There were increased levels of postoperative interferon-γ, tumor necrosis factor-α, IL-12p70, IL-1β, IL-2, IL-4, and IL-17a at 15 mm Hg when compared to 12 mm Hg., Conclusions: The data indicated that lower pressure RP reduced intra-/postoperative cytokine levels confirming our hypothesis. Larger patient numbers are required to further validate this but the implications of this data will benefit not only urological patients but also other speciality patients undergoing minimally invasive surgery., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc.)