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This article discusses a surgical technique called single-port robot-assisted nephroureterectomy (RANU) for the treatment of upper tract urothelial carcinoma (UTUC). The technique utilizes the da Vinci Single Port System (SP), which allows for smaller incisions and improved outcomes compared to multiport systems. The article provides a detailed description of the surgical technique and reports positive results in terms of operative time, blood loss, complications, pain scores, and length of stay. The authors suggest that further research comparing SP RANU to other techniques is needed, but believe it has the potential to be a competitive option for UTUC treatment. [Extracted from the article]

The article discusses the initial clinical experience of performing single-port robot-assisted partial nephrectomy using the lower anterior approach. The study included 12 cases at Rush University Medical Center, with favorable surgical outcomes and no peri-operative complications. The technique offers advantages such as minimal incisions, avoidance of the peritoneal cavity, and potential benefits for patients with previous abdominal procedures. The approach shows promise for renal masses with lower surgical complexity, with the potential for expansion to more complex cases as experience grows. [Extracted from the article]

The article discusses the technique of robot-assisted single-port transvesical enucleation of the prostate (STEP) for the surgical treatment of severe lower urinary tract symptoms (LUTS) caused by benign prostatic enlargement. The procedure involves using the Da Vinci Single Port (SP) system to perform the enucleation of the prostate through a single skin incision. The article provides a step-by-step guide to the surgical technique and presents preliminary data from a single-center experience, showing positive outcomes such as shorter hospital stays and less use of opioids compared to the standard multiport approach. The authors acknowledge the limitations of the study, including the small sample size and short follow-up period, but suggest that STEP may be a safe and effective alternative for the management of large prostate glands. [Extracted from the article]

This article is a response to a comment on a study about acupuncture for perioperative pain after open radical prostatectomy. The authors address the comment by discussing the complexity of pain experiences, the generalizability of their results, the choice of acupuncture points, and the impact of acupuncture on recovery parameters. They agree that their study opens up possibilities for non-pharmacological pain management in urology and encourage future research to explore patient diversity, qualitative results, the neurophysiological basis of acupuncture, and the implementation of acupuncture in routine care. The authors have no conflicts of interest to declare and the study has not been presented elsewhere. [Extracted from the article]

Objectives: To investigate the oncological significance of a robot‐assisted radical cystectomy (RARC)‐related pentafecta in patients with bladder cancer. Patients and Methods: Using the KORARC database, which includes data from 12 centres, data from 730 patients who underwent RARC between April 2007 and May 2019 were prospectively collected and retrospectively analysed. Pentafecta was achieved if patients met all of the following criteria: (i) negative soft tissue surgical margin; (ii) ≥16 lymph nodes removed; (iii) no major complications (Clavien–Dindo grade 3–5) within 90 days; (iv) no clinical recurrence within the first 12 months; and (v) no ureteroenteric stricture. Patients were divided into two groups according to pentafecta attainment, and a comparison of overall survival (OS) and cancer‐specific survival (CSS) using multivariate Cox proportional analysis was then carried out. Results: Of the 730 patients included in this analysis, 208 (28.5%) attained the RARC pentafecta; the remaining 522 (71.5%) did not. The mean age of the patients was 64.67 years, 85.1% were men, 53.6% received a conduit, 37.7% received orthotopic neobladders and the total complication rate was 57.8%. Those who attained the pentafecta received more neobladders (P = 0.039), were more likely to be treated with the intracorporeal technique (P < 0.001), had longer operating times (P = 0.020) and had longer console time (P = 0.021) compared with those who did not attain the pentafecta. Over a mean of 31.1 months of follow‐up, the pentafecta attainment group had significantly higher OS and CSS rates compared with the non‐attainment group (10‐year OS 70.4% vs 58.1%, respectively [P = 0.016]; 10‐year CSS 87.8% vs 70.0%, respectively [P = 0.036]). Multivariate analysis showed that the RARC pentafecta was a significant predictor of overall mortality (hazard ratio 0.561; P = 0.038). Conclusions: Patients who attained the RARC pentafecta had significantly better survival outcomes compared with those who did not. These criteria could be used to standardize assessment of the surgical quality of RARC. In the future, a similar study using an independent cohort is warranted to confirm our results. [ABSTRACT FROM AUTHOR]

Objective: To describe the crucial factors related to the implementation of the da Vinci single‐port (SP) system (Intuitive Surgical Inc., Sunnyvale, CA, USA), and the early outcomes after the introduction of this robot for robot‐assisted radical prostatectomy (RARP). Patients and methods: We prospectively collected data from 50 consecutive patients with prostate adenocarcinoma who underwent RARP using this robot. The median follow‐up was 53 days. We performed a transperitoneal technique. The robotic (multiport) trocar was placed on the supra‐umbilical midline 20 cm from the pubis and an assistant trocar placed in the right lower quadrant. We report our initial experience describing the intra‐ and postoperative outcomes associated with this new robot. Also, we report the early functional and oncological outcomes in the follow‐up period considered. Continuous variables were described as medians and interquartile ranges, while categorical variables as frequencies and proportions. Results: The median total operative time was 118 min, median console time was 80 min, and median estimated blood loss was 50 mL. There were no intraoperative complications or blood transfusions. The final pathology reported 18% Grade Group (GrGp)1, 58% GrGp2, 18% GrGp3, 2% GrGp4, and 4% GrGp5. In all, 40 patients (80%) were pT2 and 20% were ≥pT3a. The overall positive surgical margin rate was 14%. In all, 39 patients (78%) achieved full continence at median of 21 days after RARP. The median pain scale (0–10) score at 8, 12 and 16 h after RARP was 2, 2, and 0, respectively. Conclusion: The use of the da Vinci SP robot with an additional assistant port for RARP is technically safe and feasible, with acceptable short‐term functional and oncological outcomes. However, there is a technical learning curve for this new platform due to the smaller scope of the operative field and the decreased flexibility and strength of the surgical instruments. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of Retzius‐sparing robot‐assisted radical prostatectomy (posterior approach) on early recovery of urinary continence (UC) compared to the conventional approach (anterior approach) for the treatment of clinically localized prostate cancer (PCa). Methods: A total of 110 consecutive patients with clinically localized PCa were prospectively randomized in a 1:1 ratio to an anterior group (n = 55) or a posterior group (n = 55). The primary outcome was immediate UC, defined as freedom from any pad use within 1 week after removal of the urinary catheter. The UC rate following surgery was also calculated with Kaplan–Meier curves, and the log‐rank test was used for statistical comparison. Intra‐operative outcomes, pathological data and oncological outcomes, including positive surgical margin (PSM) status and biochemical recurrence‐free survival (BCRFS), were also compared between the two groups. The comparison of the two approaches was also analysed in subgroups after risk stratification. Results: Of the patients who underwent the posterior approach, 69.1% achieved immediate UC compared with 30.9% in the anterior group (relative risk 2.24, 95% confidence interval [CI] 1.48–3.51; P = 0.000). The relative Kaplan–Meier curves for UC during the 12‐month follow‐up revealed statistically better recovery in the posterior group when compared with the anterior group (hazard ratio [HR] 1.51, 95% CI 1.01–2.24; log‐rank P = 0.007). No statistically significant differences were observed between the groups regarding complications (P = 0.399), PSM status (P = 0.225) or BCRFS (HR 4.80, 95% CI 0.97–23.78; log‐rank P = 0.111). In sub‐analyses, no significant difference between the two approaches with regard to UC recovery in patients with high‐risk PCa was observed (HR 1.26, 95% CI 0.63–2.51; log‐rank P = 0.415). Conclusions: The Retzius‐sparing approach significantly improved early recovery of UC compared to the conventional approach. Further prospective studies are needed to confirm the benefits of the Retzius‐sparing approach for clinically localized PCa, especially for high‐risk cases. [ABSTRACT FROM AUTHOR]

Objective: To prospectively compare the effects of endoscopic stapling, division and suture ligation, and suture ligation with suspension of the dorsal venous complex (DVC) on continence during robot‐assisted laparoscopic radical prostatectomy (RARP). Patients and methods: In all, 300 consecutive patients undergoing RARP by a single surgeon were randomised to three groups: endoscopic stapling, cut and suture ligation, and suture ligation with suspension. The only difference between the groups was the technique to control the DVC. Pad‐free continence (PFC) and overall continence (0 pads/day with or without security pad) were assessed with patient reported pad usage records and validated questionnaires (Expanded Prostate Cancer Index) at 3, 12, and 15 months. Secondary endpoints were erectile function (EF) recovery (defined as erections sufficient for sexual activity) and the rate of apical surgical margins. Univariate and multivariate analyses were conducted to determine predictors for recovery of both urinary continence and EF. Results: The three groups were comparable in terms of age, body mass index, prostate size, American Urological Association symptom score, Sexual Health Inventory for Men, and clinical stage. There were no differences found in terms of operative times, estimated blood loss, pathological stage, and positive apical margin. There was no difference between the three groups with regard to overall continence or PFC at 3 months. However, overall continence at 15 months for ligation and suspension was 99% and was superior to stapler (88%) (P = 0.002) and cut and suture ligation (88%) (P = 0.002). Additionally, PFC at 15 months was superior for ligation and suspension (87%) as compared to stapler (73%) and cut and suture ligation (75%) (P = 0.045). The technique of DVC control did not impact EF. Men with nerve sparing had better continence compared to no nerve sparing at 3 months (62% vs 42%, P = 0.045), but not at 15 months. The median time to continence was 2 months for patients receiving nerve sparing compared to 4.5 months for non‐nerve sparing (P = 0.02). Conclusion: Suture suspension of the DVC during RARP contributes to higher overall continence rates compared to stapling and cut and suture. Nerve sparing contributes to earlier return of continence than non‐nerve sparing. [ABSTRACT FROM AUTHOR]

Objective: To investigate the influence of tumour location zone on positive surgical margin (PSM) status after Retzius‐sparing robot‐assisted radical prostatectomy (RS‐RARP). Materials and Methods: A total of 203 consecutive patients with prostate cancer (PCa) who underwent RS‐RARP at our centre were divided into three cohorts according to the tumour zonal origin described on preoperative magnetic resonance imaging (MRI). Clinical and pathological characteristics were compared among the three groups. The associations of clinicopathological variables with PSM status after RS‐RARP were also evaluated. Results: The rates of PSM in patients with transition zone (TZ) and mixed origin tumours were significantly higher than in patients with peripheral zone tumours (P < 0.01). Of the PSMs in patients with TZ and mixed origin cancers, 42.0% and 40.9%, respectively, were located at the anterior part of the gland. On multivariate analysis, presence of a TZ tumour was significantly associated with a higher PSM rate after RS‐RARP (P < 0.01). Sub‐analysis showed that high‐risk patients with TZ tumours had a higher risk of PSM after RS‐RARP (P < 0.01). Conclusion: Presence of a TZ tumour is an independent risk factor for PSMs after RS‐RARP. Preoperative identification of TZ tumours might aid surgical planning for the Retzius‐sparing technique, especially in high‐risk patients. [ABSTRACT FROM AUTHOR]

Objective: To summarize the clinical experiences with single‐port (SP) robot‐assisted radical prostatectomy (RARP) reported in the literature and to describe the peri‐operative and short‐term outcomes of this procedure. Material and Methods: A systematic review of the literature was performed in December 2019 using Medline (via PubMed), Embase (via Ovid), Cochrane databases, Scopus and Web of Science (PROSPERO registry number 164129). All studies that reported intra‐ and peri‐operative data on SP‐RARP were included. Cadaveric series and perineal or partial prostatectomy series were excluded. Results: The pooled mean operating time, estimated blood loss, length of hospital stay and catheterization time were 190.55 min, 198.4 mL, 1.86 days and 8.21 days, respectively. The pooled mean number of lymph nodes removed was 8.33, and the pooled rate of positive surgical margins was 33%. The pooled minor complication rate was 15%. Only one urinary leakage and one major complication (transient ischaemic attack) were recorded. Regarding functional outcomes, pooled continence and potency rates at 12 weeks were 55% and 42%, respectively. Conclusions: The present analysis confirms that SP‐RARP is safe and feasible. This novel robotic platform resulted in similar intra‐operative and peri‐operative outcomes to those obtained with the standard multiport da Vinci system. The advantages of single incision can be translated into a preservation of the patient's body image and self‐esteem and cosmesis, which have a great impact on a patient's quality of life. [ABSTRACT FROM AUTHOR]

Objective: To assess the influence of the 2012 US Preventive Services Task Force (USPSTF) recommendation against prostate‐specific antigen (PSA)‐based screening on oncological and functional outcomes following robot‐assisted laparoscopic prostatectomy (RALP). Materials and Methods: We retrospectively analysed patients who underwent RALP between 2008 and 2018 with a minimum of 12‐month follow‐up from a prospectively collected institutional review board‐approved database. The impact of the USPSTF recommendation against PSA screening on our surgical outcomes was assessed using a logistic regression model using two groups comprising patients treated before/after the USPSTF statement and indicating time trends for each successive year. Results: The mean preoperative PSA increased from 6.0 to 7.4 ng/mL after the USPSTF recommendation. We detected statistically significant time‐trend changes after 2012, including an increase in the positive slope of Gleason ≥3 + 4 or ≥pT3 disease. We detected a fall in bilateral full nerve‐sparing and an increase in partial nerve‐sparing. The total positive surgical margin (PSM) rate increased after the USPSTF recommendation; however, PSM rates pertinent to each pathological stage did not change significantly after 2012. There was a significant negative trend change in the postoperative 12‐month continence and potency rates, indicating a breakpoint in functional outcomes after 2012. We detected a 1.7‐fold increase in 12‐month biochemical recurrence (BCR) rates. The 12‐month BCR, potency and continence rates were maintained in young (<55 years) patients with a Sexual Health Inventory for Men score >22 and low‐volume disease. Conclusion: Since the USPSTF's recommendation in 2012, we have seen a significant increase in the incidence of high‐risk disease that has forced us to modify our approach to the procedure and the grade of nerve‐sparing used, leading to a wider resection, in order to reduce PSMs. This has led to a decrease in postoperative functional recovery. Patients with favourable characteristics had good outcomes before and after the USPSTF's recommendation, implying that the quality of surgery did not change over time. [ABSTRACT FROM AUTHOR]

Background: It has been suggested that, in comparison with open radical cystectomy (ORC), robot‐assisted radical cystectomy (RARC) results in less blood loss, shorter convalescence and fewer complications, with equivalent short‐term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits. Objectives: To assess the effects of RARC vs ORC in adults with bladder cancer. Search Methods: We conducted a comprehensive search, with no restrictions on language of publication or publication status, for randomized controlled trials (RCTs) that compared RARC with ORC. The date of the last search was 1 July 2018. Databases searched included the Cochrane Central Register of Controlled Trials, MEDLINE (1999 to July 2018), PubMed Embase (1999 to July 2018), Web of Science (1999 to July 2018), Cancer Research UK (www.cancerresearchuk.org/), and the Institute of Cancer Research (www.icr.ac.uk/). We also searched the following trial registers: ClinicalTrials.gov (clinicaltrials.gov/); BioMed Central International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com); and the World Health Organization International Clinical Trials Registry Platform. The review was based on a published protocol. Primary outcomes of the review were recurrence‐free survival and major postoperative complications (Clavien grade III to V). Secondary outcomes were minor postoperative complications (Clavien grades I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive surgical margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk‐of‐bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data. Results: We included in the review five RCTs comprising a total of 541 participants. Total numbers of participants included in the ORC and RARC cohorts were 270 and 271, respectively. We found that RARC and ORC may result in a similar time to recurrence (hazard ratio 1.05, 95% confidence interval [CI] 0.77 to 1.43; two trials, low‐certainty evidence). In absolute terms at 5 years of follow‐up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar rates of major complications (risk ratio [RR] 1.06, 95% CI 0.76 to 1.48; five trials, low‐certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence because of study limitations and imprecision. We were very uncertain whether RARC reduces minor complications (very‐low‐certainty evidence). We downgraded the certainty of evidence because of study limitations and very serious imprecision. RARC probably results in substantially fewer transfusions than ORC (RR 0.58, 95% CI 0.43 to 0.80; two trials, moderate‐certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations. RARC may result in a slightly shorter hospital stay than ORC (mean difference −0.67, 95% CI −1.22 to −0.12; five trials, low‐certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in a similar quality of life (standardized mean difference 0.08, 95% CI 0.32 lower to 0.16 higher; three trials, low‐certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar positive surgical margin rates (RR 1.16, 95% CI 0.56 to 2.40; five trials, low‐certainty evidence). This corresponds to eight more (95% CI 21 fewer to 67 more) positive surgical margins per 1000 participants, based on 48 positive surgical margins per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. Conclusions: We conclude that RARC and ORC may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive surgical margin rates (all low‐certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very‐low‐certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate‐certainty evidence) and may reduce hospital stay slightly (low‐certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost‐effectiveness. [ABSTRACT FROM AUTHOR]

Objectives: To assess the early functional and oncological outcomes of a large series of patients who underwent robot‐assisted radical perineal prostatectomy (RPP). Materials and Methods: We retrospectively analysed the patients who underwent robot‐assisted RPP for localized prostate cancer between November 2016 and September 2018. Patients who had locally advanced disease proven on biopsy or were suspected to have locally advanced disease on multiparametric magnetic resonance imaging and patients who had a contraindication for the exaggerated lithotomy position were not included in this study. Patient demographics, preoperative and postoperative variables, complications and follow‐up times were recorded. Results: A total of 95 patients were included. Their mean ± sd age was 61.5 ± 6.5 years. The median (interquartile range [IQR]) preoperative prostate‐specific antigen level was 6.1 (3.7) ng/mL, the median (IQR) operating time was 140 (25) min, and the mean ± sd blood loss was 67.4 ± 17 mL. Pelvic lymph node dissection (PLND) was performed for 12 patients (12.6%). The median (IQR) hospital stay was 1 (1) days. Positive surgical margins were present in eight patients (8.4%). After catheter removal, the immediate continence rate was 41%. Continence rates were 78%, 87% and 91%, respectively, 3, 6 and 12 months after surgery. Potency rates were 49%, 69% and 77%, respectively, 3, 6 and 12 months after surgery for patients who had adequate potency preoperatively. The median (IQR) follow‐up time was 13 (3.1) months. Conclusion: We conclude that robot‐assisted RPP is a reliable and effective surgical technique that can be employed in the treatment of localized prostate cancer regardless of prostate volume, especially in patients with a history of abdominal surgery. As an additional advantage, PLND can be performed through the same incision. [ABSTRACT FROM AUTHOR]

Objective: To analyse whether selective arterial clamping (SAC) and off‐clamp (OC) techniques during robot‐assisted partial nephrectomy (RPN) are associated with a renal functional benefit in patients with Stage 3–5 chronic kidney disease (CKD). Patients and methods: The change in estimated glomerular filtration rate (eGFR) over time was compared between 462 patients with baseline CKD 3–5 that underwent RPN with main arterial clamping (MAC) (n = 375, 81.2%), SAC (n = 48, 10.4%) or OC (n = 39, 8.4%) using a multivariable linear mixed‐effects model. All follow‐up eGFRs, including baseline and follow‐up between 3 and 24 months, were included in the model for analysis. The median follow‐up was 12.0 months (interquartile range 6.7–16.5; range 3.0–24.0 months). Results: In the multivariable linear mixed‐effects model adjusting for characteristics including tumour size and the R.E.N.A.L. (Radius; Exophytic/Endophytic; Nearness; Anterior/Posterior; Location) Nephrometry Score, the change in eGFR over time was not significantly different between SAC and MAC RPN (β = −1.20, 95% confidence interval [CI] −5.45, 3.06; P = 0.582) and OC and MAC RPN (β = −1.57, 95% CI −5.21, 2.08; P = 0.400). Only 20 (15 MAC, two SAC, three OC) patients overall had progression of their CKD stage at last follow‐up. The mean ischaemia time was 17 min for MAC and 15 min for SAC. There was no benefit to SAC or OC in terms of blood loss, perioperative complications, length of stay, or surgical margins. Conclusion: SAC and OC techniques during RPN were not associated with benefit in preservation of eGFR in patients with baseline CKD. [ABSTRACT FROM AUTHOR]

Objectives: To incorporate and validate clinically relevant performance metrics of simulation (CRPMS) into a hydrogel model for nerve‐sparing robot‐assisted radical prostatectomy (NS‐RARP). Materials and Methods: Anatomically accurate models of the human pelvis, bladder, prostate, urethra, neurovascular bundle (NVB) and relevant adjacent structures were created from patient MRI by injecting polyvinyl alcohol (PVA) hydrogels into three‐dimensionally printed injection molds. The following steps of NS‐RARP were simulated: bladder neck dissection; seminal vesicle mobilization; NVB dissection; and urethrovesical anastomosis (UVA). Five experts (caseload >500) and nine novices (caseload <50) completed the simulation. Force applied to the NVB during the dissection was quantified by a novel tension wire sensor system fabricated into the NVB. Post‐simulation margin status (assessed by induction of chemiluminescent reaction with fluorescent dye mixed into the prostate PVA) and UVA weathertightness (via a standard 180‐mL leak test) were also assessed. Objective scoring, using Global Evaluative Assessment of Robotic Skills (GEARS) and Robotic Anastomosis Competency Evaluation (RACE), was performed by two blinded surgeons. GEARS scores were correlated with forces applied to the NVB, and RACE scores were correlated with UVA leak rates. Results: The expert group achieved faster task‐specific times for nerve‐sparing (P = 0.007) and superior surgical margin results (P = 0.011). Nerve forces applied were significantly lower for the expert group with regard to maximum force (P = 0.011), average force (P = 0.011), peak frequency (P = 0.027) and total energy (P = 0.003). Higher force sensitivity (subcategory of GEARS score) and total GEARS score correlated with lower nerve forces (total energy in Joules) applied to NVB during the simulation with a correlation coefficient (r value) of −0.66 (P = 0.019) and −0.87 (P = 0.000), respectively. Both total and force sensitivity GEARS scores were significantly higher in the expert group compared to the novice group (P = 0.003). UVA leak rate highly correlated with total RACE score r value = −0.86 (P = 0.000). Mean RACE scores were also significantly different between novices and experts (P = 0.003). Conclusion: We present a realistic, feedback‐driven, full‐immersion simulation platform for the development and evaluation of surgical skills pertinent to NS‐RARP. The correlation of validated objective metrics (GEARS and RACE) with our CRPMS suggests their application as a novel method for real‐time assessment and feedback during robotic surgery training. Further work is required to assess the ability to predict live surgical outcomes. [ABSTRACT FROM AUTHOR]

Objectives: To compare salvage robot‐assisted laparoscopic prostatectomy (RALP) outcomes in patients who underwent radiation and those who underwent focal ablation as primary therapies. Patients and Methods: We evaluated 126 patients who underwent salvage RALPbetween 2008 and 2018. Of these, 94 (74.6%) received radiation and 32 focal ablation (25.4%) as primary therapy. These groups were compared with regard to clinical, oncological and functional outcomes. Kaplan–Meier curves and regression models were used to identify survival estimations and their predictors. Results: Before surgery, more patients were potent in the focal ablation group compared to the radiation group (46.9% vs 22.6%; P = 0.013). Peri‐operative characteristics and complication rates were not significantly different between the two groups. Postoperative catheterization duration was shorter in the focal ablation group (mean 10 vs 16 days; P = 0.018). At final pathology, the focal ablation group had higher non‐organ‐confined disease (71% vs 50%; P = 0.042) and positive surgical margin (PSM) rates (43.8% vs 17%; P = 0.004) as compared to the radiation group; however, 5‐year biochemical recurrence (BCR)‐free survival rates were similar (59% vs 56%; P = 0.761). Postoperative 1‐year full (no pads/day) and social (0–1 pad/day) continence rates were significantly higher in the focal ablation as compared to the radiation group (77.3% vs 39.2%, P = 0.002, and 87.5% vs 51.3%, P = 0.002, respectively). Multivariate analyses showed primary focal ablation and nerve‐sparing to be predictors of postoperative continence. Erectile function was preserved in 13% and 27% of preoperatively potent patients in the radiation and focal ablation groups, respectively (P = 0.435). No predictors were identified for postoperative potency. Conclusions: Radiation was associated with inferior functional outcomes after salvage RALP. Focal therapies were associated with higher non‐organ‐confined disease and PSMrates, with no significant difference in short‐term BCR‐free survival. [ABSTRACT FROM AUTHOR]

Objectives: To summarize the current evidence on Retzius‐sparing (RS)‐robot‐assisted radical prostatectomy (RARP) and to compare its oncological, peri‐operative and functional outcomes with those of standard retropubic RARP (S‐RARP). Materials and Methods: After establishing an a priori protocol, a systematic electronic literature search was conducted in January 2019 using the Medline (via PubMed), Embase (via Ovid) and Cochrane databases. The search strategy relied on the 'PICO' (Patient Intervention Comparison Outcome) criteria and article selection was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Only studies reporting the oncological and functional outcomes of RARP (as determined by type of procedure [RS‐RARP vs S‐RARP]) were considered for inclusion. Risk of bias and study quality were assessed. Finally, peri‐operative and functional outcomes were recorded and analysed. Results: A shorter operating time was associated with RS‐RARP (weighted mean difference [WMD] 14.7 min, 95% confidence interval [CI] −28.25, 1.16; P = 0.03), whereas no significant difference was found in terms of estimated blood loss (WMD 1.45 mL, 95% CI −31.18, 34.08; P = 0.93). Also, no significant difference between the two groups was observed for overall (odds ratio [OR] 0.86, 95% CI 0.40, 1.85; P = 0.71) and major (Clavien >3; OR 0.88, 95% CI 0.30, 2.57) postoperative complications; however, the likelihood of positive surgical margins (PSMs) was lower for the S‐RARP group (rate 15.2% vs 24%; OR 1.71, 95% CI 1.12, 2.60; P = 0.01). The cumulative analysis showed a statistically significant advantage for RS‐RARP in terms of continence recovery at 1 month (OR 2.54, 95% CI 1.16, 5.53; P = 0.02), as well as at 3 months (OR 3.86, 95% CI 2.23, 6.68; P < 0.001), 6 months (OR 3.61, 95% CI 1.88, 6.91; P = 0.001), and 12 months (OR 7.29, 95% CI 1.89, 28.13; P = 0.004). Conclusion: Our analysis confirms that RS‐RARP is a safe and feasible alternative to S‐RARP. This novel approach may be associated with faster and higher recovery of continence, without increasing the risk of complications. One caveat might be the higher risk of PSMs, and this can be regarded as a current pitfall of the technique, probably related to an expected learning curve. [ABSTRACT FROM AUTHOR]

Objective: To propose a standardisable composite method for reporting outcomes of radical cystectomy (RC) that incorporates both perioperative morbidity and oncological adequacy. Patients and methods: From July 2010 to December 2017, 277 consecutive patients who underwent robot‐assisted RC with intracorporeal urinary diversion (UD) for bladder cancer at our Institution were prospectively analysed. Patients who simultaneously demonstrated negative soft tissue surgical margins (STSMs), ≥16 lymph node (LN) yield, absence of major (grade III–IV) complications at 90 days, absence of UD‐related long‐term sequelae and absence of clinical recurrence at ≤12 months, were considered as having achieved the RC‐pentafecta. A multivariable logistic regression model was assessed to measure predictors for achieving RC‐pentafecta. Results and limitations: Since 2010, 270 of 277 patients that had completed at least 12 months of follow‐up were included. Over a mean follow‐up of 22.3 months, ≥16 LN yield, negative STSMs, absence of major complications at 90 days, and absence of UD‐related surgical sequelae and clinical recurrence at ≤12 months were observed in 93.0%, 98.9%, 76.7%, 81.5% and 92.2%, patients, respectively, resulting in a RC‐pentafecta rate of 53.3%. Multivariable logistic regression analysis revealed age (odds ratio [OR] 0.95; P = 0.002), type of UD (OR 2.19; P = 0.01) and pN stage (OR 0.48; P = 0.03) as independent predictors for achieving RC‐pentafecta. Conclusions: We present a RC‐pentafecta as a standardisable composite endpoint that incorporates perioperative morbidity and oncological adequacy as a potential tool to assess quality of RC. This tool may be useful for assessing the learning curve and calculating cost‐effectiveness amongst others but needs to be externally validated in future studies. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the clinical trend changes in our robot‐assisted laparoscopic prostatectomy (RALP) practice and to investigate the effect of 2012 US Preventive Services Task Force (USPSTF) statement against PSA screening on these trends. Patients and Methods: Data of 10 000 RALPs performed by a single surgeon between 2002 and 2017 were retrospectively analysed. Time trends in successive 1000 cases for clinical, surgical and pathological characteristics were analysed with linear and logistic regression. Time‐trend changes before and after the USPSTF's statement were compared using a logistic regression model and likelihood‐ratio test. Results: Unfavourable cancer characteristics rate, including D'Amico high risk, pathological non‐organ‐confined disease and Gleason score ≥4+4 increased from 11.5% to 23.3%, 14% to 42.5%, and 7.7% to 20.9%, respectively, over time (all P < 0.001). Significant time‐trend changes were detected after the USPSTF's statement with an increase in the positive trend of Gleason ≥4+4 and increase in the negative trends of Gleason ≤3+4 tumours. There was a significant negative trend in the rate of full nerve‐sparing (NS) with a decrease from 59.3% to 35.7%, and a significant positive trend in partial NS with an increase from 15.8% to 62.5% over time (both P < 0.001). The time‐trend slope in 'high‐grade' partial NS significantly decreased and 'low‐grade' partial NS significantly increased after the USPSTF's statement. The overall positive surgical margin rate increased from 14.6% to 20.3% in the first vs last 1000 cases (P < 0.001), with a significant positive slope after the USPSTF's statement. Conclusions: The proportion of high‐risk patients increased in our series over time with a significant impact of the USPSTF's statement on pathological time trends. This stage migration resulted in decreased utilisation of high‐quality NS and increased performance of poor‐quality NS. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the incidence and survival outcomes of histological variants of upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU). Materials and Methods: We retrospectively analysed data from 1610 patients treated with RNU for clinically non‐metastatic UTUC between 1990 and 2016 in several centres participating in the UTUC Collaboration. Histological variants were classified as micropapillary, squamous, sarcomatoid and other, including other rare variants (<10 cases for each). Multivariable competing risk analyses were conducted to assess the effect of variant histology on overall recurrence and cancer‐specific mortality (CSM). Results: Overall, 1460 patients (91%) had pure urothelial carcinoma (PUC), whereas 150 (9%) were diagnosed with a variant histology, including 89 (5.0%), 41 (2.0%), 10 (1.0%) and 10 (1.0%) cases of micropapillary, squamous, sarcomatoid and other tumours, respectively. Variant histology was associated with the presence of adverse pathological features compared with PUC, including non‐organ‐confined disease (59% vs 38%; P < 0.001), lymph node invasion (28% vs 24%; P = 0.02), high‐grade disease (88% vs 71%; P < 0.001), tumour necrosis (28% vs 16%; P = 0.001) and positive surgical margins (15% vs 8%; P = 0.01). In competing risk analysis, micropapillary variant was the only factor associated with worse recurrence (sub‐hazard ratio [SHR] 2.27, 95% confidence interval [CI] 1.25–4.79; P = 0.02) whereas sarcomatoid variant was associated with worse CSM (SHR 16.8, 95% CI 6.86–41.17; P < 0.001). Conclusion: We found that one out of 10 patients with UTUC treated with RNU had variant histology. Only micropapillary and sarcomatoid variants were associated with poorer oncological outcomes after adjusting for available confounding factors. [ABSTRACT FROM AUTHOR]

Objectives: To describe a step‐by‐step technique for robot‐assisted radical cystectomy (RARC) with pelvic lymph node dissection (PLND) performed using the da Vinci® SP™ surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Patients and Methods: Four consecutive patients diagnosed with urothelial carcinoma of the bladder were counselled for RARC with PLND and ileal conduit urinary diversion performed using the da Vinci SP surgical system. A 3‐cm midline incision was made 5‐cm above the umbilicus. Dissection was performed to access the abdominal cavity. Insertion of the GelPOINT® advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) with the SP Cannula was performed through the incision made. A 12‐mm AirSeal® (SurgiQuest Inc., Milfort, CT, USA) port for the assistant was placed on the pre‐marked stoma site, where an ileal conduit urinary diversion was desired. Demographics and perioperative outcomes were collected under Institutional Review Board approval (IRB 13‐780). The surgeries were performed by reproducing the steps of the institutional approach for RARC performed with the multi‐arm robotic platform. Results: The surgeries were successfully completed. There was neither conversion to standard multi‐arm robotic or open approaches nor the need for additional port placement. The mean (range) operative time was 454 (420–496) min. Blood loss averaged 312 mL. No transfusions were required and no intraoperative complications occurred. All patients had negative surgical margins. All patients were discharged on postoperative day 5. Conclusion: From our preliminary experience, RARC with PLND and ileal conduit urinary diversion is feasible and safe using the da Vinci SP surgical system. Further comparative studies with open and multi‐arm robotic approaches are warranted. [ABSTRACT FROM AUTHOR]

Introduction: Prostatic capsular incision (CapI) is an iatrogenic breach of the prostatic capsule during radical prostatectomy (RP) that can cause positive surgical margins (PSMs) in organ‐confined (pT2) prostate cancer, or the retention of benign prostatic tissue. We systematically interrogated the literature in order to clarify the definition of CapI, and the implications of this event for rates of PSM and biochemical recurrence (BCR). Methods: A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) criteria using the search terms 'capsular incision' AND 'prostatectomy', and variations of each. In all, 18 studies were eligible for inclusion. Results: A total of 51 057 RP specimens were included. The incidence of CapI ranged from 1.3% to 54.3%. CapI definitions varied and included a breach of the prostatic capsule 'exposing both benign or malignant prostate cancer cells', 'malignant tissue only', or 'benign tissue only'. The incidence of PSMs due to CapI ranged from 2.8% to 71.7%. Our meta‐analysis results found that when CapI was defined as 'exposing malignant tissue only in organ‐confined prostate cancer' there was an increased risk of BCR compared to patients with pT2 disease and no CapI (relative risk 3.53, 95% confidence interval 2.82–4.41; P < 0.001). Conclusions: The absolute impact of CapI on oncological outcomes is currently unclear due to inconsistent definitions. However, the data imply an association between CapI and PSMs and BCR. Reporting of possible areas of CapI on the operation note, or marking areas of concern on the specimen, are critical to assist CapI recognition by the pathologist. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of length of time from diagnostic biopsy to radical prostatectomy (RP) on oncological outcomes amongst men diagnosed with unfavourable intermediate‐ to very‐high‐risk clinically localised prostate cancer. Patients and methods: We performed a retrospective review of men with a diagnosis of grade group (GG) ≥3 prostate cancer on biopsy, who underwent RP within 6 months of diagnosis, at our institution between 2005 and 2018. We assessed patient demographics, pre‐biopsy disease characteristics, and receipt of neoadjuvant therapy. We categorised time between biopsy and RP into two intervals: <3 and 3–6 months. For each GG, we compared receipt of adjuvant therapy, pathological outcomes at RP (positive surgical margin [PSM], extraprostatic extension [EPE], seminal vesicle invasion [SVI], and lymph node involvement [LNI]), risk of 2‐ and 5‐year biochemical recurrence‐free survival (BCRFS), and 2‐, 5‐, and 10‐year metastasis‐free survival (MFS) between patients who underwent RP at <3 vs 3–6 months after diagnosis. Results: Amongst 2303 men who met the study inclusion criteria, 1244 (54%) had GG 3, 608 (26%) had GG 4, and 451 (20%) had GG 5 disease. In all, 72% underwent RP at <3 months after diagnosis. For each diagnostic GG, there was no significant difference in rates of adjuvant therapy, PSM, EPE, SVI, or LNI in men who had RP at <3 vs 3–6 months after diagnosis. In all, 1568 men had follow‐up after RP of >1 year. For each diagnostic GG, there was no significant difference in 2‐ and 5‐year BCRFS between patients who had RP at <3 vs 3–6 months after diagnosis (GG 3: 78% vs 83% and 69% vs 66%, respectively, P = 0.6; GG 4: 68% vs 74% and 51% vs 57%, respectively, P = 0.4; GG 5: 58% vs 74% and 48% vs 54%, respectively, P = 0.2). Similarly, for each diagnostic GG, there was no significant difference in 2‐, 5‐, and 10‐year MFS between patients who had RP at <3 vs 3–6 months after diagnosis, although we were not able to calculate 10‐year MFS for patients with GG 5 disease due to limited follow‐up in that group (GG 3: 98%, 92%, and 84% vs 97%, 95%, and 91%, respectively, P = 0.4; GG 4: 97%, 90%, and 72% vs 94%, 91%, and 81%, respectively, P = 0.8; GG 5: 89% and 81% vs 91% and 71%, respectively, P = 0.9). Conclusions: Waiting for RP up to 6 months after diagnosis is not associated with adverse outcomes amongst patients with unfavourable intermediate‐ to very‐high‐risk prostate cancer. [ABSTRACT FROM AUTHOR]

Objectives: To characterise bone scan use, and potential overuse, after radical prostatectomy (RP) using data from a large, national integrated delivery system. Overuse of imaging is well documented in the setting of newly diagnosed prostate cancer, but whether overuse persists after RP remains unknown. Patients and methods: We identified 12 269 patients with prostate cancer treated with RP between 2005 and 2008 using the Veterans Administration Central Cancer Registry. We used administrative and laboratory data to examine rates of bone scan use, including preceding prostate‐specific antigen (PSA) levels, and receipt of adjuvant or salvage therapy. We then performed multivariable logistic regression to identify factors associated with post‐RP bone scan use. Results: At a median follow‐up of 6.8 years, one in five men (22%) underwent a post‐RP bone scan at a median PSA level of 0.2 ng/mL. Half of bone scans (48%) were obtained in men who did not receive further treatment with androgen‐deprivation or radiation therapy. After adjustment, post‐RP bone scan was associated with a prior bone scan (adjusted odds ratio [aOR] 1.55, 95% confidence interval [CI] 1.32–1.84), positive surgical margin (aOR 1.68, 95% CI 1.40–2.01), preoperative PSA level (aOR 1.02, 95% CI 1.01–1.03), as well as Hispanic ethnicity, Black race, and increasing D'Amico risk category, but not with age or comorbidity. Conclusion: We found a substantial rate of bone scan utilisation after RP. The majority were performed for PSA levels of <1 ng/mL where the likelihood of a positive test is low. More judicious use of imaging appears warranted in the post‐RP setting. [ABSTRACT FROM AUTHOR]

Objective: To compare oncological, functional and surgical outcomes of open retropubic radical prostatectomy (ORP) vs robot‐assisted laparoscopic radical prostatectomy (RARP). Patients and methods: We identified 10 790 consecutive treated patients within our prospective database (2008–2016) who underwent either ORP (7007 patients) or RARP (3783). All procedures were performed by seven highly trained surgeons performing both surgical approaches regularly. Oncological (48‐month biochemical recurrence [BCR] rate), functional (urinary continence, erectile function), and surgical outcomes (rate of nerve‐sparing [NS] procedures, lymph node yield, surgical margin [SM] status, length of hospital stay [LOS], operation time, blood loss, transfusion rate, time to catheter removal) were assessed. Kaplan–Meier, multivariable Cox and logistic regression models were used to test for BCR and functional outcome differences. Results: No statistically significant difference regarding oncological outcome distinguished between ORP vs RARP. For functional outcomes, the 1‐week continence rates were higher in the ORP group (25.8% vs 21.8%, P < 0.001). At 3 months, no statistically significant differences were observed. At 12 months, continence rates were modestly higher in the RARP group (90.3% vs 88.8%, P = 0.01). This effect was no longer observed after stratification for age‐groups. The 12‐month potency rates were similar in ORP vs RARP (80.3% vs 83.6%, P = 0.33). For surgical outcomes, there was no significant difference in the rates of NS procedures, lymph node yield, SM status, and LOS. Conversely, operation time was shorter in ORP, and blood loss, transfusion rates and time to catheter removal were significantly lower in RARP. Conclusions: Both surgical approaches, performed in a high‐volume centre by the same surgeons, achieve excellent, comparable oncological and functional outcomes. However, a modest advantage for RARP for surgical outcomes was observed, most likely attributable to its minimally invasive nature, and better teaching capabilities. Consequently, more than the surgical approach itself, the well‐trained surgeon remains the most important factor to achieve satisfactory outcomes. [ABSTRACT FROM AUTHOR]

Objectives: To develop a nomogram for predicting side‐specific extracapsular extension (ECE) for planning nerve‐sparing radical prostatectomy. Materials and Methods: We retrospectively analysed data from 561 patients who underwent robot‐assisted radical prostatectomy between February 2014 and October 2015. To develop a side‐specific predictive model, we considered the prostatic lobes separately. Four variables were included: prostate‐specific antigen; highest ipsilateral biopsy Gleason grade; highest ipsilateral percentage core involvement; and ECE on multiparametric magnetic resonance imaging (mpMRI). A multivariable logistic regression analysis was fitted to predict side‐specific ECE. A nomogram was built based on the coefficients of the logit function. Internal validation was performed using 'leave‐one‐out' cross‐validation. Calibration was graphically investigated. The decision curve analysis was used to evaluate the net clinical benefit. Results: The study population consisted of 829 side‐specific cases, after excluding negative biopsy observations (n = 293). ECE was reported on mpMRI and final pathology in 115 (14%) and 142 (17.1%) cases, respectively. Among these, mpMRI was able to predict ECE correctly in 57 (40.1%) cases. All variables in the model except highest percentage core involvement were predictors of ECE (all P ≤ 0.006). All variables were considered for inclusion in the nomogram. After internal validation, the area under the curve was 82.11%. The model demonstrated excellent calibration and improved clinical risk prediction, especially when compared with relying on mpMRI prediction of ECE alone. When retrospectively applying the nomogram‐derived probability, using a 20% threshold for performing nerve‐sparing, nine out of 14 positive surgical margins (PSMs) at the site of ECE resulted above the threshold. Conclusion: We developed an easy‐to‐use model for the prediction of side‐specific ECE, and hope it serves as a tool for planning nerve‐sparing radical prostatectomy and in the reduction of PSM in future series. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of hospital volume (HV) and surgeon volume (SV) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN). Patients and Methods: All consecutive patients who underwent a RAPN from 2009 to 2015, at 11 institutions, were included in a retrospective study. To evaluate the impact of HV, we divided RAPN into four quartiles according to the caseload per year: low HV (<20/year), moderate HV (20-44/year), high HV (45-70/year), and very high HV (>70/year). The SV was also divided into four quartiles: low SV (<7/year), moderate SV (7-14/year), high SV (15-30/year), and very high SV (>30/year). The primary endpoint was the Trifecta defined as the following combination: no complications, warm ischaemia time (WIT) <25 min, and negative surgical margins. Results: In total, 1 222 RAPN were included. The mean (SD) caseload per hospital per year was 44.9 (26.7) RAPNs and the mean (SD) caseload per surgeon per year was 19.2 (14.9) RAPNs. The Trifecta achievement rate increased significantly with SV (69.9% vs 72.8% vs 73% vs 86.1%; P < 0.001) and HV (60.3% vs 72.3% vs 86.2% vs 82.4%; P < 0.001). The positive surgical margins (PSM) rate (P = 0.02), length of hospital stay (LOS; P < 0.001), WIT (P < 0.001), and operative time (P < 0.001), all decreased significantly with increasing SV. The PSM rate (P = 0.02), LOS (P < 0.001), WIT (P < 0.001), operative time (P < 0.001), and major complications rate (P = 0.01), all decreased significantly with increasing HV. In multivariate analysis adjusting for HV and SV (model 3), HV remained the main predictive factor of Trifecta achievement (odds ratio [OR] 3.70 for very high vs low HV; P < 0.001), whereas SV was not associated with Trifecta achievement (OR 1.58 for very high vs low SV; P = 0.34). Conclusion: In this multicentre study HV and SV both greatly influenced RAPN perioperative outcomes, but HV appeared to have a greater impact than SV. [ABSTRACT FROM AUTHOR]

Objectives: To compare peri-operative outcomes after robot-assisted partial nephrectomy (RAPN) for cT2a (7 to <10 cm) to cT1 tumours. Materials and Methods: Patients with a cT1a (n = 1 358, 76.4%), cT1b (n = 379, 21.3%) or cT2a (n = 41, 2.3%) renal mass were identified from a multi-institutional RAPN database. Intra- and postoperative outcomes were compared for cT2a masses vs cT1a and cT1b masses using multivariable regression models (linear, logistic, Poisson etc.), adjusting for operating surgeon and a modified R.E.N.A.L. nephrometry score that excluded the radius component. Results: The median sizes for cT1a, cT1b and cT2a tumours were 2.5, 5.0 and 8.0 cm, respectively (P < 0.001) with modified R.E.N.A.L. nephrometry scores being 6.0, 6.5 and 7.0, respectively (cT1a, P < 0.001; cT1b, P = 0.105). RAPN for cT2a vs cT1a masses was associated with a 12% increase in operating time (P < 0.001), a 32% increase in estimated blood loss (P < 0.001), a 7% increase in ischaemia time (P = 0.008), a 3.93 higher odds of acute kidney injury at discharge (95% confidence interval [CI] 1.33, 8.76; P = 0.009) and a higher risk of recurrence (hazard ratio [HR] 10.9, 95% CI 1.31, 92.2; P = 0.027). RAPN for cT2a vs cT1b masses was associated with a 12% increase in blood loss (P = 0.036), a 5% increase in operating time (P = 0.062) and a marginally higher risk of recurrence (HR 11.2, 95% CI 0.77, 11.5; P = 0.059). RAPN for cT2a tumours was not associated with differences in complications (cT1a, P = 0.535; cT1b, P = 0.382), positive margins (cT1a, P = 0.972; cT1b, P = 0.681), length of stay (cT1a, P = 0.507; cT1b, P = 0.513) or renal function decline up to 24 months post-RAPN (cT1a, P = 0.124; cT1b, P = 0.467). Conclusion: For T2a tumours RAPN is a feasible treatment option in a select patient population when performed by experienced surgeons in institutions equipped to manage postoperative complications. Although RAPN was associated with greater blood loss and longer operating and ischaemia time in T2a tumours, it was not associated with greater complication or positive surgical margin rates compared with T1 tumours. Renal function preservation rates were equivalent for up to 24 months postoperatively; however, 12-month recurrencefree survival was significantly lower in the T2a group. Extended follow-up is required to further evaluate long-term survival. [ABSTRACT FROM AUTHOR]

Objectives: To compare the characteristics of lesions detected or undetected by template‐guided transperineal saturation prostate biopsy and to evaluate the potential impact of undetected lesions. Materials and Methods: We evaluated the characteristics of lesions in radical prostatectomy (RP) specimens, compared the differences between lesions detected and undetected by systematic transperineal ultrasonography‐guided 11‐region biopsy with regard to tumour volume, Gleason score, surgical margin, spatial location and clinical significance, and assessed the potential impact of undetected clinically significant lesions. Results: The median number of biopsy cores was 24. Sixty‐four percent of the clinically significant lesions (170/264) were detected. There were significant differences between the detected and undetected lesions in tumour volume, Gleason score and clinical significance. Inconsistencies found in lesion position between biopsy and RP specimens in the anterior and posterior zones and the left and right sides was 3.4% (7/203) and 5.4% (11/203), respectively. Of the 129 patients, 13 (10.1%) were found to have undetected clinically significant lesions in the biopsy lying on the same side but in a different zone from the detected clinically significant lesions, whereas 23 patients (17.8%) had undetected clinically significant lesions in the biopsy lying on the opposite side from the detected clinically significant lesions. Conclusions: Template‐guided transperineal saturation prostate biopsy detected approximately two‐thirds of clinically significant lesions. Most of the undetected lesions were those with small tumour volume. Approximately 20–30% of patients had clinically significant undetected lesions in a different lobe or different quadrant from the detected lesions in the biopsy. [ABSTRACT FROM AUTHOR]

Objectives: To analyse the outcomes of robot‐assisted partial nephrectomy (RAPN) in patients with a solitary kidney in a large multi‐institutional database. Patients and Methods: In all, 2755 patients in the Vattikuti Collective Quality Initiative database underwent RAPN by 22 surgeons at 14 centres in nine countries. Of these patients, 74 underwent RAPN with a solitary kidney between 2007 and 2016. We retrospectively analysed the functional and oncological outcomes of these 74 patients. A ‘trifecta’ of outcomes was assessed, with trifecta defined as a warm ischaemia time (WIT) of <20 min, negative surgical margins, and no complications intraoperatively or within 3 months of RAPN. Results: All 74 patients underwent RAPN successfully with one conversion to radical nephrectomy. The median (interquartile range [IQR]) operative time was 180 (142–230) min. Early unclamping was used in 11 (14.9%) patients and zero ischaemia was used in 12 (16.2%). Trifecta outcomes were achieved in 38 of 66 patients (57.6%). The median (IQR) WIT was 15.5 (8.75–20.0) min for the entire cohort. The overall complication rate was 24.1% and the rate of Clavien–Dindo grade ≤II complications was 16.3%. Positive surgical margins were present in four cases (5.4%). The median (IQR) follow‐up was 10.5 (2.12–24.0) months. The median drop in estimated glomerular filtration rate at 3 months was 7.0 mL/min/1.72 m2 (11.01%). Conclusion: Our findings suggest that RAPN is a safe and effective treatment option for select renal tumours in solitary kidneys in terms of a trifecta of negative surgical margins, WIT of <20 min, and low operative and perioperative morbidity. [ABSTRACT FROM AUTHOR]

Objective To evaluate the impact of preoperative risk category on metastatic disease and prostate cancer-specific mortality ( CSM) in patients with prostate cancer ( PCa) with adverse pathology at radical prostatectomy ( RP). Patients and Methods The records of 6 943 patients who underwent RP at a European tertiary centre were analysed. Biochemical recurrence ( BCR), metastatic disease and CSM were assessed for patients with adverse pathology at RP, and stratified according to preoperative low- vs intermediate-/high-risk PCa groups. Kaplan-Meier, cumulative incidence, Cox regression and competing risk regression analyses were performed. Results In patients with extracapsular extension, the metastatic disease rate was 1.6% vs 8% ( P < 0.001) and the CSM rate was 2% vs 5% ( P = 0.041) for low vs intermediate-/high-risk patients, respectively, at 10 years. In patients with pathological Gleason score ≥3+4, the metastatic disease rate was 3.0% vs 12% ( P < 0.001) and the CSM rate was 3% vs 8%, respectively ( P < 0.001). In patients with positive surgical margins ( PSMs), the metastatic disease rate was 2.9% vs 15% ( P < 0.001) and the CSM rate was 4% vs 10%, respectively ( P = 0.0001). Low-risk status was a predictive factor for metastatic disease in patients with pathological Gleason score ≥3+4 (hazard ratio [ HR] 0.51), pathological Gleason score ≥4+3 ( HR 0.41) and PSMs ( HR 0.46) and was a predictive factor for CSM risk in patients with pathological Gleason score ≥3+4 ( HR 0.62). Conclusions Patients with low-risk PCa were at significantly lower risk of metastatic disease and CSM than their intermediate-/high-risk counterparts, when adverse pathological features were identified at RP. This should be emphasized in the decision-making process after RP. [ABSTRACT FROM AUTHOR]

Objective To describe a multicentre experience of robot-assisted partial nephrectomy (RAPN) in northern England, with focus on early surgical outcomes and oncological results. Patients and Methods All consecutive patients undergoing RAPN at four tertiary referral centres in northern England in the period 2012-2015 were included for analysis. RAPN was performed via a transperitoneal approach using a standardized technique. Prospective data collection was performed to capture preoperative characteristics (including R.E.N.A.L. nephrometry score), and peri-operative and postoperative data, including renal function. Correlations between warm ischaemia time (WIT), positive surgical margin (PSM) rate, complication rates, R.E.N.A.L. nephrometry scores and learning curve were assessed using univariate and multivariate analyses. Results A total of 250 patients (mean age 58.1 - 13 years, mean - SD body mass index 27.3 - 7 kg/m2) were included, with a median (range) follow-up of 12 (3-36) months. The mean - SD tumour size was 30.6 - 10 mm, mean R.E.N.A.L. nephrometry score was 6.1 - 2 and 55% of tumours were left-sided. Mean - SD operating console time was 141 - 38 min, WIT 16.7 - 8 min and estimated blood loss 205 - 145 mL. There were five conversions (2%) to open/ radical nephrectomy. The overall complication rate was 16.4% (Clavien I, 1.6%; Clavien II, 8.8%; Clavien III, 6%; Clavien IV/V; 0%). Pathologically, 82.4% of tumours were malignant and the overall PSM rate was 7.3%. The mean - SD preoperative and immediate postoperative estimated glomerular filtration rates were 92.8 - 27 and 80.8 - 27 mL/ min/1.73 m2, respectively (P = 0.001). In all, 66% of patients remained in the same chronic kidney disease category postoperatively, and none of the patients required dialysis during the study period. 'Trifecta' (defined as WIT < 25 min, negative surgical margin status and no peri-operative complications) was achieved in 68.4% of patients overall, but improved with surgeon experience. PSM status and long WIT were significantly associated with early learning curve. Conclusion This is the largest multicentre RAPN study in the UK. Initial results show that RAPN is safe and can be performed with minimal morbidity. Early oncological outcomes and renal function preservation data are encouraging. [ABSTRACT FROM AUTHOR]

Objective To report on patients undergoing robot-assisted partial cystectomy ( RAPC), focusing on perioperative outcomes over a range of clinical, anatomical and pathological variables, as well as the overall oncological efficacy of this approach. Patients and Methods We retrospectively reviewed all patients who underwent RAPC by a single surgeon between 2005 and 2015. We identified 29 patients who underwent surgery for definitive management of a primary bladder tumour. Clinicopathological data and perioperative variables were recorded. Continuous variables were compared using the Student's t-test. Prediction of perioperative outcomes for those undergoing RAPC for intra-diverticular neoplasms was done using univariate logistic regression. Survival was estimated using the Kaplan-Meier method. Results The median (interquartile range) patient age was 75 (65-81) years, 18 patients (62.1%) had an American Society of Anesthesiologists classification of ≥3, and 10 patients (34.5%) had a history of prior abdominal surgery. The median estimated blood loss ( EBL) was 50 mL and the median length of stay ( LOS) was 1 day. Two patients (6.9%) had a perioperative complication and five (17.9%) a post-discharge complication at ≤90 days, all of which were minor. The positive surgical margin rate was 3.6% and in those with muscle-invasive disease a median of 12 lymph nodes were removed. Neither the size of diverticulum nor the need for ureteric re-implantation was predictive of LOS, EBL, or complication ( P > 0.05). We did not encounter any wound, port site, or unusual recurrence patterns to suggest the technical factors of a robotic approach influenced oncological outcomes. The 5-year overall and recurrence-free survival rates were 79% and 68%, respectively. Conclusion RAPC confers the ability to achieve favourable outcomes with low morbidity and reduced hospital stays. Oncological efficacy compares favourably with the published literature. For experienced surgeons, this may represent the optimal surgical approach for organ-preserving bladder surgery. [ABSTRACT FROM AUTHOR]

Objective To assess the efficacy of light-reflectance spectroscopy ( LRS) to detect positive surgical margins ( PSMs) on ex vivo radical prostatectomy ( RP) specimens. Materials and Methods A prospective evaluation of ex vivo RP specimens using LRS was performed at a single institution from June 2013 to September 2014. LRS measurements were performed on selected sites on the prostate capsule, marked with ink, and correlated with pathological analysis. Significant features on LRS curves differentiating malignant tissue from benign tissue were determined using a forward sequential selection algorithm. A logistic regression model was built and randomised cross-validation was performed. The sensitivity, specificity, accuracy, negative predictive value ( NPV), positive predictive value ( PPV), and area under the receiver operating characteristic curve ( AUC) for LRS predicting PSM were calculated. Results In all, 50 RP specimens were evaluated using LRS. The LRS sensitivity for Gleason score ≥7 PSMs was 91.3%, specificity 92.8%, accuracy 92.5%, PPV 73.2%, NPV 99.4%, and the AUC was 0.960. The LRS sensitivity for Gleason score ≥6 PSMs was 65.5%, specificity 88.1%, accuracy 83.3%, PPV 66.2%, NPV 90.7%, and the AUC was 0.858. Conclusions LRS can reliably detect PSMs for Gleason score ≥7 prostate cancer in ex vivo RP specimens. [ABSTRACT FROM AUTHOR]

Objectives To verify retrospectively the margin status and analyse the location and characteristics of positive surgical margins ( PSMs) in patients undergoing radical prostatectomy ( RP), by a central pathology review, based on the consensus conference 2009 updated margin criteria from the International Society of Urological Pathology ( ISUP). Patients and Methods The detailed PSM characteristics of 441 patients who underwent laparoscopic RP ( LRP) between 1999 and 2007 were centrally reviewed with regard to location, number, Gleason score at the PSM and tumour width. Predictors of PSMs and the impact of several PSM characteristics on clinical outcomes were examined. Patient characteristics were compared using the chi-squared test. Differences in recurrence-free survival ( RFS) rates were analysed using the log-rank test and presented as Kaplan-Meier survival curves. Univariable and multivariable Cox regression analysis for the prediction of RFS was performed. Results Central pathology review using the updated PSM definition according to ISUP 2009, resulted in reclassification of a substantial number of patients with PSMs ( n = 113, 26.6%) as R0. Several PSM characteristics with a higher risk of biochemical recurrence ( BCR) were identified as the strongest independent predictors of RFS: pathological stage; Gleason score; and the presence of multiple PSMs (hazard ratio [ HR] 1.78; 95% confidence interval [ CI] 1.08-2.96; P = 0.025). Further analysis replacing the location of PSM by the width categories of PSM showed that a PSM >3 mm was an independent predictor of RFS ( HR 1.72; 95% CI 1.08-2.72; P = 0.022). Conclusions The impact of PSMs after LRP for prostate cancer remains unclear. PSMs in the present cohort of patients undergoing LRP had different characteristics and conferred different risks of BCR. A better understanding of PSM characteristics and a careful standardized pathological evaluation is needed to adequately counsel patients with respect to prognosis and adjuvant therapy after LRP. [ABSTRACT FROM AUTHOR]

Objectives To evaluate partial nephrectomy (PN) use in patients at higher risk for clinical progression, using a large national database of American patients. Patients and Methods We performed a retrospective review of patients with cN0/ cM0 renal cell carcinoma from 2003 to 2011 using the National Cancer Data Base. Our primary endpoint was PN use for high-risk disease, defined as ≥1 adverse pathological features (APF), namely pT3 stage, high grade, or unfavourable histology. Our secondary endpoint was positive surgical margins (PSM) associated with high-risk disease after PN. Time trends were analysed using the asymptotic Cochran–Armitage trend test. Relationships between patient, provider, and pathological factors and the likelihood of PN were assessed using multivariate logistic regression. Results Of 183 886 surgically treated patients, 27.4% underwent PN. Over time, PN use increased overall (17.4.39.7%) and in tumours with ≥1 APF (8.5–24.2%) (P < 0.01). In patients with ≥1 APF, multivariate analysis revealed that academic practice setting and high surgical volume were positively associated with PN use, while increasing tumour size and preoperative biopsy were negatively associated with its use (P < 0.01). The PSM rate after PN also increased significantly over time in all patients and in those harbouring adverse pathology (P < 0.01). Aside from time, older age, larger tumour size, community hospital type, and robotic approach were associated with PSM in the setting of APF (P < 0.01). Conclusion PN use for patients with adverse pathology is increasing and is associated with increasing PSM. The long-term oncological implications of these trends are unclear and warrant further study. [ABSTRACT FROM AUTHOR]

Objective To assess the impact of positive surgical margins ( PSMs) on long-term outcomes after radical prostatectomy ( RP), including metastasis, castrate-resistant prostate cancer ( CRPC), and prostate cancer-specific mortality ( PCSM). Patients and Methods Retrospective study of 4 051 men in the Shared Equal Access Regional Cancer Hospital ( SEARCH) cohort treated by RP from 1988 to 2013. Proportional hazard models were used to estimate hazard ratios ( HRs) of PSMs in predicting biochemical recurrence (BCR), CRPC, metastases, and PCSM. To determine if PSMs were more predictive in certain patients, analyses were stratified by pathological Gleason score, stage, and preoperative prostate-specific antigen ( PSA) level. Results The median (interquartile range) follow-up was 6.6 (3.2-10.6) years and 1 127 patients had >10 years of follow-up. During this time, 302 (32%) men had BCR, 112 (3%) developed CRPC, 144 (4%) developed metastases, and 83 (2%) died from prostate cancer. There were 1 600 (40%) men with PSMs. In unadjusted models, PSMs were significantly associated with all adverse outcomes: BCR, CRPC, metastases and PCSM (all P ≤ 0.001). After adjusting for demographic and pathological characteristics, PSMs were associated with increased risk of only BCR ( HR 1.98, P < 0.001), and not CRPC, metastases, or PCSM ( HR ≤1.29, P > 0.18). Similar results were seen when stratified by pathological Gleason score, stage, or PSA level, and when patients who underwent adjuvant radiotherapy were excluded. Conclusions PSMs after RP are not an independent risk factor for CRPC, metastasis, or PCSM overall or within any subset. In the absence of other high-risk features, PSMs alone may not be an indication for adjuvant radiotherapy. [ABSTRACT FROM AUTHOR]

Objective To assess the influence of tumour zonality on biochemical recurrence ( BCR) after radical prostatectomy ( RP) with a histologically confirmed positive surgical margin ( PSM). Patients and Methods Data from 382 patients that underwent RP with either transition zone ( TZ) or peripheral zone ( PZ) tumours involving PSMs between 1998 and 2010 were retrieved from the Abbott West Australian Prostatectomy Database. Statistical analysis was used to evaluate the relationship of various tumour clinicopathological parameters, e.g. zonal origin of tumour, tumour volume, Gleason score, and stage to the development of BCR Results There were 51 TZ and 331 PZ tumours with PSMs identified. The TZ tumours compared with PZ tumours were larger (median 5.67 vs 3.64 mL, P < 0.001), more frequently lower grade ( Gleason score 6 33% vs 5%, P < 0.01), organ confined (51% vs 35.6%, P = 0.073), and preferentially involved the bladder neck (49% vs 6%, P < 0.001). Tumour zonality was not associated with BCR for the entire cohort. TZ and PZ tumours had similar 5-year BCR-free survival rates (58% vs 63%, P = 0.691) and comparable time to development of BCR (14.4 vs 19.2 months, P = 0.346). On univariate analysis, preoperative PSA level, PSM at the bladder neck, tumour volume, Gleason score ( P < 0.001) and tumour stage were independent predictors of BCR for the entire cohort. On multivariate analysis tumour volume and Gleason score retained significance as independent predictors of BCR. Tumour zonality was not directly associated with BCR. Of the patients who received adjuvant therapy, the incidence of BCR was similar for TZ and PZ tumours (58% vs 67%, P = 0.077), although TZ tumours failed significantly earlier (mean 4.4 vs 16.4 months, P = 0.037). Conclusions PSA recurrence in patients with histologically confirmed PSMs after RP is independent of the zonal location of the index tumour. However, tumour zonal origin may have an indirect influence on PSA relapse, as TZ tumours tend to be of large volume and more likely involve the bladder neck margin, both risk factors for BCR. Bladder neck margin involvement is associated with higher rates of BCR than other sites of PSMs. The preoperative identification of TZ tumours might aid surgical planning with appropriate alteration of RP technique to incorporate wider surgical margins at the bladder neck. Adjuvant radiotherapy appears to be associated with adverse outcome for TZ tumours, a novel finding which warrants further investigation. [ABSTRACT FROM AUTHOR]

Objective To evaluate the role of positive surgical margin ( PSM) size/focality and location in relation to risk of biochemical recurrence ( BCR) after robot-assisted radical prostatectomy ( RARP)., Patients and Methods Clinicopathological data were collected from 904 patients who underwent RARP at a single European institution from 2002 to 2006., PSM status after RARP was defined as cancer cells at the inked margin, and was stratified by size/focality and location., The outcome variable was BCR, defined as a postoperative PSA level of ≥0.2 ng/mL., We modelled clinicopathological covariates including PSM size/focality and location using Cox proportional hazards regression. In subgroup analyses, we assessed the effect of PSM size and location at different pathological stages and grades of disease., Results Compared with negative SM, a PSM of >3 mm/multifocal was associated with an increased risk of BCR in the entire cohort (hazard ratio [ HR] 2.84, 95% confidence interval 1.76-4.59), while unifocal PSMs of ≤3 mm were not significantly associated with BCR., In subgroup analyses, the negative impact of >3 mm/multifocal PSM appeared greatest in those with lower postoperative stage and grade of disease., The prognostic role of PSM location was unconfirmed, although data indicated that posterolateral PSMs may be of lower significance in RARP patients., The study is limited by lack of central pathology review, and lack of statistical adjustment for tumour volume, lymph node status, and surgeon volume., Conclusion We found that men with >3 mm/multifocal PSMs have a higher risk of BCR than those with unifocal PSMs of ≤3 mm or negative SMs, especially if they have lower risk disease., Posterolateral margins may be of little significance in a RARP population. [ABSTRACT FROM AUTHOR]

Objectives To assess the cost, quality of life ( QoL) and cost-effectiveness of a single-incision mini-sling ( SIMS; Ajust®, C. R. Bard Inc., New Providence, NJ, USA) compared with a standard mid-urethral sling ( SMUS; TVT- O™, Ethicon Inc., Somerville, NJ, USA) in the surgical management of female stress urinary incontinence., Patients and Methods A total of 137 women, in a secondary care setting, were randomized between October 2009 and October 2011 to undergo SIMS placement ( n = 69) under local anaesthesia as an opt-out policy or SMUS placement ( n = 68) under general anaesthesia., Clinical outcome measures included the patient-reported success rate (Patient Global Impression of Improvement [ PGI- I]) and the impact on the patients' QoL ( King's Health Questionnaire [ KHQ])., Health economic data (cost and quality-adjusted life year [ QALY] data) were compared using linear regression models to generate an incremental cost per QALY estimate, in order to determine a measure of cost-effectiveness., Deterministic sensitivity analyses investigated uncertainty in the results, and non-parametric bootstrapping techniques were used to estimate a probability of cost-effectiveness., Results There were no significant differences between the groups in terms of the KHQ total score ( P = 0.27) or the patient-reported success rate ( P = 1.00, odds ratio: 0.895; 95% confidence interval [ CI]: 0.344 to 2.330)., There was no significant difference in QALYs for the SIMS group compared with the SMUS group (mean difference: −0.003; 95% CI: −0.008 to +0.002)., The SIMS was on average less costly, −£142.41 95% CI: (−316.99 to 32.17) and generated cost savings of £48 419 per QALY loss with 94% probability of cost savings to the health services., Taking a wider perspective on the costing analysis by including the wider community benefit associated with the significantly earlier return to work observed in the SIMS group ( P = 0.006, 95% CI: 11.756 to 17.217), there was an increase in cost savings to −£477, (95% CI: −823.65 to −129.63), with a probability of 100% of cost savings to the wider economy., Conclusions The adjustable anchored SIMS ( Ajust), performed under local anaesthesia as an opt-out policy, delivers cost savings to the health service provider when compared with the SMUS ( TVT- O), and is likely to be cost-effective up to 1 year after placement., Further research should be undertaken to confirm the results of our study over longer follow-up and should explore patient preferences alongside an adequately powered non-inferiority randomized controlled trial. [ABSTRACT FROM AUTHOR]

Objectives To present our laparoscopic partial nephrectomy ( LPN) results according to the margin, ischaemia and complications ( MIC) system recently proposed for the standardized reporting of partial nephrectomy ( PN) outcomes., To assess the role of learning curve and tumour anatomical characteristics on the outcomes by using MIC system., Patients and Methods Data were obtained from our prospectively maintained LPN database, including only patients who underwent LPN performed with vascular clamping., According to the MIC system definition, the goal of LPN was reached (i.e. MIC was achieved) when surgical margins were negative, warm ischaemia time ( WIT) was <20 min and no major complications occurred., Patients were stratified by quartiles of distribution, named LPN eras 1-4, and MIC rates in different LPN eras were compared, evaluating the impact of learning curve and tumour anatomical characteristics (as assessed by Preoperative Aspects and Dimensions Used for an Anatomical [ PADUA] score on the outcomes., Results The study population consisted of 206 patients., The overall MIC rate was 63.1%: it progressively increased along the learning curve, reaching 84.9% in LPN era 4 ( P < 0.001)., PADUA-score risk group categories were inversely correlated with MIC score ( P = 0.001)., When simultaneously considering the effects of both LPN eras and PADUA-score risk group categories, a trend towards a higher MIC rate was found in the latest series, regardless of tumour anatomical characteristics., When MIC score components were separately analysed, WIT decreased significantly from LPN era 1 to LPN era 4 ( P < 0.001) and from PADUA-score risk group categories 3 to 1 ( P = 0.001), A trend towards a decrease in the complication rate along the learning curve was observed ( P = 0.251), while LPN era and PADUA score together significantly influenced the complications rate ( P < 0.001). The positive surgical margin rate was very low (2.9% overall) and stable throughout the case study., Conclusion The MIC rate increased with surgeon's experience and decreased when complex lesions were treated., The MIC system was found to be an easy, useful and reproducible tool to report LPN data series. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? The ideal treatment for men with high-risk prostate cancer is controversial, although most physicians agree that a multimodal approach, including radiation and hormone therapy with or without surgery, offers the best chance of cancer control. Minimally-invasive radical prostatectomy has emerged as a treatment option for clinically localized cancer; however, critics argue that the open approach may afford advantages of tactile feedback and a better lymph node dissection., The present study demonstrates that open and minimally-invasive radical prostatectomy offer equivalent short-term outcomes for men with high-risk prostate cancer at a highly experienced centre., Objectives To analyze pathological and short-term oncological outcomes in men undergoing open and minimally-invasive radical prostatectomy ( MIRP) for high-risk prostate cancer ( HRPC; prostate-specific antigen level [ PSA] >20 ng/ mL, ≥ cT2c, Gleason score 8-10) in a contemporaneous series., Patients and Methods In total, 913 patients with HRPC were identified in the Johns Hopkins Radical Prostatectomy Database subsequent to the inception of MIRP at this institution (2002-2011), Of these, 743 (81.4%) underwent open radical retropubic prostatectomy ( ORRP), 105 (11.5%) underwent robot-assisted laparoscopic radical prostatectomy ( RALRP) and 65 (7.1%) underwent laparoscopic radical prostatectomy ( LRP) for HRPC., Appropriate comparative tests were used to evaluate patient and prostate cancer characteristics., Proportional hazards regression models were used to predict biochemical recurrence., Results Age, race, body mass index, preoperative PSA level, clinical stage, number of positive cores and Gleason score at final pathology were similar between ORRP and MIRP., On average, men undergoing MIRP had smaller prostates and more organ-confined ( pT2) disease ( P = 0.02)., The number of surgeons and surgeon experience were greatest for the ORRP cohort., Overall surgical margin rate was 29.4%, 34.3% and 27.7% ( P = 0.52) and 1.9%, 2.9% and 6.2% ( P = 0.39) for pT2 disease in men undergoing ORRP, RALRP and LRP, respectively., Biochemical recurrence-free survival among ORRP, RALRP and LRP was 56.3%, 67.8% and 41.1%, respectively, at 3 years ( P = 0.6) and the approach employed did not predict biochemical recurrence in regression models., Conclusions At an experienced centre, MIRP is comparable to open radical prostatectomy for HRPC with respect to surgical margin status and biochemical recurrence. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Positive surgical margin ( PSM) frequency after radical cystectomy has been estimated to be 4-15%. Studies that have not distinguished between the different sites of PSM have failed to show that they are an independent prognostic factor for disease-free survival. Only perivesical soft tissue PSMs have been associated with an increased risk of cancer recurrence and cancer-specific death., This is the first comprehensive published analysis of PSMs occurring during radical cystectomy for pTx pN0 M0 bladder cancer according to their location, comparing their cancer-specific survival ( CSS) and other outcomes with those of a control group paired according to TNM status, age, sex and urinary diversion method. Local recurrence-free survival rates were found to be lower in patients with both soft tissue and urethral PSMs. Moreover, soft-tissue PSMs were associated with lower metastatic recurrence-free and CSS rates., Objective To compare the prognoses associated with positive surgical margins ( PSMs) according to their urethral, ureteric and/or soft tissue locations in patients with pN0 M0 bladder cancer who have not undergone neoadjuvant chemotherapy., Patients and Methods A retrospective, case-control study was conducted between 1991 and 2011 using data from 17 academic centres in France., A total of 154 patients (cases) with PSMs met the eligibility criteria and were matched according to centre, p T stage, gender, age and urinary diversion method with a population-based sample of 154 patients (controls) from 3651 patients who had undergone cystectomies., The median follow-up period was 23.9 months., Multivariable Cox regression analysis was used to test the effects of PSMs on local recurrence ( LR)-free survival, metastatic recurrence ( MR)-free survival and cancer-specific survival ( CSS)., Results The 5-year LR-free survival and CSS rates of patients with urethral and soft tissue PSMs were lower than those in the control group., A significant decrease in CSS was associated with soft tissue PSMs ( P = 0.003, odds ratio = 0.425, 95% confidence interval 0.283-0.647). The prognosis was not affected in cases of ureteric PSMs., Conclusions Soft tissue PSMs were associated with poor CSS rates in patients with pN0 M0 bladder cancer., A correlation between urethrectomy and a reduction of the risk of LR in a urethral PSM setting was observed. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? HistoScanning™ is a novel ultrasonography technique for visualization of prostate cancer. The technology it uses and its encouraging results in prostate cancer foci detection in 29 men with prostate cancer have been described previously. A recent study confirmed these results in 31 patients. The sensitivity and specificity of prostate cancer foci detection were 90% and 72%, respectively. These promising results raised the question of whether HistoScanning™ technology might also be helpful in therapy planning., Preoperative knowledge of the distribution and size of tumours might be useful for treatment planning of a nerve-sparing radical prostatectomy. We tested the ability of HistoScanning™ to predict a negative surgical margin in 80 patients undergoing radical prostatectomy., Objective To assess the accuracy of HistoScanning™ ( HS) as a visualization tool for preoperative treatment planning for nerve-sparing ( NS) radical prostatectomy ( RP)., Patients and Methods A retrospective study was carried out on 80 patients with prostate cancer undergoing RP from October 2009 to December 2009., All patients underwent a HS procedure 1 day before surgery., Frozen sections ( FSs) were performed on each latero-posterior side of the prostate to assess for the presence of cancer., On the HS analysis, the region corresponding to that removed at FS was assessed for suspicious lesions. The size of suspicious lesions within this volume was compared with the FS histopathological analysis., Results HS results corresponded to a 93% probability of having a negative surgical margin in the FSs. The presence of a HS volume ≥0.2 mL in a specific side was associated with a 3.7 times increased risk of a positive surgical margin at FS., Conclusions HS has the potential to assist in the planning of NSRP., Larger, multicentre studies need to be performed for validation of these encouraging results. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Both the treatment and reconstruction after resection of penoscrotal extramammary Paget's disease (EMPD) are of concern among oncological urologists. Reconstruction of large skin defects after wide local resection of this disease remains challenging and skilled work. For the first time, by using scrotal skin flaps, we have introduced an effective and reliable procedure into the new area of reconstruction for penoscrotal EMPD in selected patients, with satisfactory functional and aesthetic results. OBJECTIVE To introduce an effective procedure for reconstruction of large skin defects after wide local resection of penoscrotal extramammary Paget's disease (EMPD) in selected patients using scrotal skin flaps without compromising oncological control., PATIENTS AND METHODS From January to June 2010 this procedure was carried out in five selected patients with penoscrotal EMPD who underwent wide local resection with subsequent reconstruction using scrotal skin flaps., Patient demographics, lesion characteristics, surgical margins and outcomes were evaluated., Skin defects covered 48-96 cm2 (median = 72 cm2). The median (range) duration of follow-up was 24 (22-27) months., RESULTS Flaps survived with satisfactory functional and aesthetic results., All patients survived without local or systemic recurrence of tumour., CONCLUSIONS Wide local resection can provide cure in superficial penoscrotal EMPD., The described method using scrotal skin flaps seems to be a safe and effective procedure for the reconstruction of large defects. [ABSTRACT FROM AUTHOR]

Study Type - Diagnostic (exploratory cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Surgical margin status at radical prostatectomy (RP) has been shown to be a predictor of disease progression and the strongest predictor of benefit from adjuvant therapy, but the impact of a positive surgical margin (PSM) on long-term prostate-cancer-specific survival is unknown. The PSM rate is dependent on the pathological stage of the cancer. In a recent multicentre nomogram for 15-year prostate-cancer-specific mortality (PCSM) after RP, PSM was not significantly associated with PCSM, while Gleason score and pathological stage were the only significant predictors. This has not been validated in a single centre, and PSM has been shown to vary greatly with surgical technique. This is the first study on the impact of PSM on PCSM in a single surgeon's cohort. In other centres, the decision to administer adjuvant therapy may be influenced by surgical margin status. In this cohort, men routinely did not receive adjuvant therapy, affording the unique opportunity to study the long-term implications of a PSM. OBJECTIVE To examine the relative impact of a positive surgical margin (PSM) and other clinicopathological variables on prostate-cancer-specific mortality (PCSM) in a large retrospective cohort of patients undergoing radical prostatectomy (RP)., PATIENTS AND METHODS Between 1982 and 2011, 4569 men underwent RP performed by a single surgeon., Of the patient population, 4461 (97.6%) met all the inclusion criteria., The median (range) age was 58 (33-75) years and the median prostate-specific antigen (PSA) was 5.4 ng/mL; RP Gleason score was ≤6 in 2834 (63.7%), 7 in 1351 (30.3%), and 8-10 in 260 (6.0%) patients; PSMs were found in 462 (10.4%) patients., Cox proportional hazards models were used to determine the impact of a PSM on PCSM., RESULTS At a median (range) follow-up of 10 years (1-29), 187 men (4.3%) had died from prostate cancer., The 20-year prostate-cancer-specific survival rate was 75% for those with a PSM and 93% for those without., Compared with those with a negative surgical margin, men with a PSM were more likely to be older (median age 60 vs 58 years) and to have undergone RP in the pre-PSA era (36.6% vs 11.8%). Additionally, they were more likely to have a higher PSA level (median 7.6 vs 5.2 ng/mL), a Gleason score of ≥7 (58.7% vs 33.7%), and a non-organ-confined tumour (90.9% vs 30.6% [ P < 0.001 for all])., In a univariate model for PCSM, PSM was highly significant (hazard ratio [HR] 5.0, 95% confidence interval [CI] 3.7-6.7, P < 0.001)., In a multivariable model, adjusting for pathological variables and RP year, PSM remained an independent predictor of PCSM (HR 1.4, 95% CI 1.0-1.9, P= 0.036) with a modest effect relative to RP Gleason score (HR 5.7-12.6) and pathological stage (HR 2.2-11.0 [ P < 0.001])., CONCLUSION Although a PSM has a statistically significant adverse effect on prostate-cancer-specific survival in multivariable analysis, Gleason grade and pathological stage were stronger predictors. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Positive surgical margins (PSMs) after radical prostatectomy are common, although their impact on the risk of disease recurrence is unknown. We examined the impact of PSMs on the risk of 'significant' biochemical recurrence stratified by their risk of occult metastatic disease. We find that only in intermediate-risk disease does the presence of a PSM have a significant impact on the risk of recurrence, and this represents a failure of technique. By contrast, for high- and low-risk disease, the risk of recurrence is driven by intrinsic tumour biology, and the presence of a PSM has little impact on outcome. OBJECTIVE To determine the impact of surgical margin status on the risk of significant biochemical recurrence (prostate-specific antigen [PSA] doubling time <3, <6 or <9 months) after prostatectomy., MATERIALS AND METHODS Patients undergoing radical prostatectomy with complete clinical and pathological data and detailed PSA follow-up were identified from two prospectively recorded databases., Patients were stratified according to their risk of occult systemic disease (low risk: PSA < 10 ng/dL, pT2 stage and Gleason score ≤6; intermediate risk: PSA 10-20 ng/dL, pT2 stage and/or Gleason score 7; high: PSA > 20 ng/dL or pT3-4 stage or Gleason score 8-10) and the impact of a positive surgical margin (PSM) within each stratum determined by univariable and multivariable analysis., RESULTS Of 1514 patients identified, 276 (18.2%), 761 (50.3%) and 477 (31.5%) were classified as having low-, intermediate- and high-risk disease respectively., A total of 370 (24.4%) patients had a PSM and with a median follow-up of 22.2 months, and 165 (7%) patients had a biochemical recurrence., Sufficient PSA data was available to calculate PSA doubling times in 151/165 patients (91.5%)., The PSM rate rose significantly, from 11% in low-risk to 43% in high-risk disease ( P < 0.001), with similar positive associations noted with tumour grade, stage and serum PSA ( P < 0.001)., Patients with low-risk disease had essentially identical risks of significant biochemical recurrence over the study period, regardless of surgical margin status. By contrast, in patients with both intermediate- and high-risk disease, a PSM was a strong predictor of significant biochemical recurrence on univariable analysis. On multivariable analysis, howver, PSM predicted significant disease recurrence in intermediate-risk disease only., CONCLUSIONS PSM is a risk factor for significant biochemical recurrence only in intermediate risk disease. [ABSTRACT FROM AUTHOR]

The article focuses on the two-stage repair of hypospadias with inner preputial layer Wolfe graft. It mentions the materials used in the surgery including optical loupes, polypropylene monofilament sutures, and Foley catheter. It discusses the surgical steps including complete manual adhesiolysis, incision at a side of the preputial skin strip, and placing of polypropylene monofilament stay sutures on all sides of the glans margin.