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Purpose: The aim of the study was to evaluate frequency of financial toxicity among patients who underwent robot-assisted radical prostatectomy for prostate cancer. Materials and Methods: Data of 1,479 robot-assisted radical prostatectomy patients between 2006-2021 reporting no financial toxicity in preoperative assessments were included retrospectively. Financial toxicity was measured with financial impact of European Organisation for Research and Treatment of Cancerquality of life questionnaire-C30. Financial impact scores were collected preoperatively, 6, 12, 18, and 24 months after robot-assisted radical prostatectomy. Results: The frequency of financial toxicity was 8.3% (122/1379; 95% CI 7.0-9.8) at any point in time throughout 2 years of follow-up. Patients reporting financial toxicity (63 [58-68]) were significantly younger than patients who had no financial toxicity (65 [61-69]; P [ .001). There was no statistically significant difference between financial toxicityD and financial toxicity + groups in terms of salvage radiotherapy (P [ .8) and positive surgical margin (P [ .2) rates. In functional assessments, clinically significant International Prostate Symptom Score and International Consultation on Incontinence QuestionnairedShort Form score increase of financial toxicityD patients (34% and 62%) were more frequent than financial toxicity( patients (23% and 47%; P [ .004 and P [ .002, respectively). In multivariable analysis, age at robot-assisted radical prostatectomy, International Prostate Symptom Score, International Consultation on Incontinence QuestionnairedShort Form, and quality of life scores were associated with financial toxicity (P < .001, OR 0.95 [95% CI 0.92-0.98]; P [ .015, OR 2.4 [95% CI 1.2-4.7]; P [ .032, OR 1.5 [95% CI 1.2-2.5]; P [ .01, OR 0.09 [95% CI 0.01-0.57], respectively). Patients who underwent robot-assisted radical prostatectomy before retirement (65 years) had a 1.6-fold increased financial toxicity risk (P [ .003, 95% CI 1.1-2.3). Conclusions: Financial toxicity after robot-assisted radical prostatectomy is low in mid-term follow-up. Patients who report urological symptoms after robotassisted radical prostatectomy should also be evaluated for financial toxicity. Required measures against financial toxicity should be taken especially in the follow-up of younger cancer survivors. [ABSTRACT FROM AUTHOR]

Purpose: Laparoscopic and robotic surgery have traditionally been performed with pneumoperitoneum of 12-15 mmHg. Based upon our previous retrospective study showing an advantage to using ultralow pneumoperitoneum during robotic prostatectomy (RP), we performed a randomized, double-blinded, controlled trial of RP at 6 mmHg vs 15 mmHg to assess postoperative pain and opioid use. Materials and Methods: Patients undergoing RP with lymphadenectomy by a single surgeon were randomized to pneumoperitoneum pressures of 6 mmHg vs 15 mmHg. Pain scores and opioid use were recorded every 2 hours until discharge. Groups underwent intention-to-treat analysis on the primary outcome of pain scores up to 8 hours after post-anesthesia care unit. Results: A total of 138 patients were randomized to RP at 6 mmHg or 15 mmHg (67 and 71, respectively). Mean console time was 7 minutes longer at 6 mmHg (135 vs 128 minutes, p=0.02). Mean estimated blood loss was similar (p=0.4) with no transfusions in either group. Most patients were discharged on the same day as surgery (88% vs 84%, p=0.5). There was no statistically significant difference observed in morphine equivalents administered during surgery or used postoperatively, yet 6 mmHg patients had lower immediate (0-4 hours) mean pain scores (2.1 vs 3.5, p <0.01) and lower maximum pain scores (3.0 vs 5.2, p <0.01). Shoulder pain was lower in 6 mmHg patients (0.03 vs 0.15, p=0.01), as was groin pain (0.6 vs 1.2 p=0.01). Patients reported flatus earlier with 6 mmHg (mean 1.0 day vs 1.3 days, p <0.01). Conclusions: Pneumoperitoneum pressure of 6 mmHg during RP has several advantages over the commonly used level of 15 mmHg without any identified disadvantages. Surgeons should consider using lower insufflation pressures. [ABSTRACT FROM AUTHOR]

Purpose: We sought to evaluate outcomes of lymph node dissection (LND) in patients with upper tract urothelial carcinoma. Materials and Methods: We performed a multicenter retrospective analysis utilizing the ROBUUST (for RObotic surgery for Upper Tract Urothelial Cancer Study) registry for patients who did not undergo LND (pNx), LND with negative lymph nodes (pN0) and LND with positive nodes (pND). Primary and secondary outcomes were overall survival (OS) and recurrence-free survival (RFS). Multivariable analyses evaluated predictors of outcomes and pathological node positivity. Kaplan-Meier analyses (KMAs) compared survival outcomes. Results: A total of 877 patients were analyzed (LND performed in 358 [40.8%]/pND in 73 [8.3%]). Median nodes obtained were 10.2 for pND and 9.8 for pN0. Multivariable analyses noted increasing age (OR 1.1, p <0.001), pND (OR 3.1, p <0.001) and pathological stage pTis/3/4 (OR 3.4, p <0.001) as predictors for all-cause mortality. Clinical high-grade tumors (OR 11.74, p[0.015) and increasing tumor size OR 1.14, p[0.001) were predictive for lymph node positivity. KMAs for pNx, pN0 and pNDdemonstrated 2-year OS of 80%, 86% and 42% (p <0.001) and 2-year RFS of 53%, 61% and 35% (p <0.001), respectively. KMAs comparing pNx, pN0 -10 nodes and pN0 <10 nodes showed no significant difference in 2-year OS (82% vs 85% vs 84%, p[0.6) but elicited significantly higher 2-year RFS in the pN0 -10 group (60% vs 74% vs 54%, p[0.043). Conclusions: LND during nephroureterectomy in patients with positive lymph nodes provides prognostic data, but is not associated with improved OS. LND yields -10 in patients with clinical node negative disease were associated with improved RFS. In high-grade and large tumors, lymphadenectomy should be considered. [ABSTRACT FROM AUTHOR]

Purpose: Robot-assisted radical prostatectomy (RARP) is associated with poorer postoperative urinary continence in older men. However, published studies reporting conflicting results have design limitations with insufficient data at the extremes of age. The purpose of this study was to assess the effect of age on post-RARP urinary continence. Materials and Methods: This study included 5,648 patients from 2 prospective Australian databases who underwent a primary RARP for prostate cancer between 2008 and 2019. Significant urinary bother and pad-usage were evaluated 12 months post-RARP by EPIC-26 (Expanded Prostate Cancer Index Composite) questionnaires, independently collected by third parties. Multivariable logistic regression was used to investigate the relationship between continence and age. Results: Percentages of significant bother increased with age: 4.2%, 6.8% 9.1% and 12.9% at age groups <55, 55-64, 65e74 and -75 years, respectively. Compared with men aged 65-69 years, the odds of significant bother in patients <55 years was significantly lower (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.32e0.75, p[0.001). Corresponding OR found no significant difference in bother in patients -70 (OR 1.24, 95% CI 0.94e1.63, p[0.13) or -75 years (OR 1.41, 95% CI 0.88e2.25, p[0.16). Pad-free rates markedly decreased with age: 86%, 79%, 68% and 50% at ages, <55, 55-64, 65e74 and -75 years, respectively. Corresponding social continence (0e1 pads/day) rates also decreased with age: 98%, 96%, 92% and 85%. Conclusions: Urinary bother and pad-usage post-RARP are excellent in young men but worsen with age. Older patients were only slightly more likely to be "significantly bothered" by incontinence despite higher pad-usage. [ABSTRACT FROM AUTHOR]

Purpose: Radical cystectomy (RC) with urinary diversion (UD) is still considered a complex surgery associated with significant morbidity. Open RC (ORC) remains the reference option of treatment, even if adoption of robot-assisted RC (RARC) is rapidly increasing. To date, all the available randomized controlled trials were characterized by an extracorporeal approach in performing UD, undermining potential benefits of a totally minimally invasive procedure. In this study, we aimed to report perioperative and 6-month outcomes from the first RCT comparing ORC and RARC with totally intracorporeal UD. Materials and Methods: Patients were eligible for randomization if they had a diagnostic transurethral resection of bladder tumor with cT2-4, cN0, cM0 or recurrent high-grade nonmuscle-invasive bladder cancer and no anesthesiological contraindications to robotic surgery. Patients were enrolled with a covariate adaptive randomization process based on the following variables: body mass index, American Society of Anesthesiologists-score, baseline hemoglobin, planned UD, neoadjuvant chemotherapy and cT stage. The primary end point was to demonstrate the superiority of RARC with intracorporeal UD in terms of a 50% transfusion rate reduction. Results: Overall, 116 consecutive patients (58 RARC, 58 ORC) were enrolled. Among primary endpoint, overall perioperative transfusion rates were significantly lower in the RARC cohort (RARC: 22% vs ORC: 41%; p[0.046). Conclusions: This prospective randomized trial observed 22% and 41% overall perioperative transfusion rates in patients treated by RARC and ORC, respectively, confirming a significant benefit in favor of RARC with intracorporeal UD. However, perioperative complications, hospital stay and 6-month health-related quality of life were largely comparable between groups. Oncologic and functional outcomes will be assessed at longer followup to observe potential differences between arms. [ABSTRACT FROM AUTHOR]

Purpose: Robotic reconstructive and extirpative procedures have been widely utilized for surgical management of various conditions in pediatric urology. Outpatient laparoscopic surgery has become the standard in cases of orchidopexy, inguinal hernia repair and varicocelectomy. There is a growing body of evidence that robotic surgery for more complex conditions can also be performed in an outpatient setting. The aim of the study was to assess the short-term safety and feasibility of robotic reconstructive and extirpative procedures for various pediatric urological conditions as scheduled outpatient procedures. Materials and Methods: Demographic information and perioperative data were prospectively collected in an institutional database for all pediatric patients undergoing outpatient robotic surgery from June 2012 to December 2019. Primary outcomes included rates of 30-day complications, emergency room visits and readmissions. Results: A total of 135 pediatric patients underwent robotic procedures in an outpatient setting. The majority underwent pyeloplasty (62) or extravesical ureteral reimplantation (55). Ten patients underwent ureteroureterostomy and 8 patients underwent extirpative procedures (nephrectomy, hemi-nephrectomy). Median age at surgery was 62 months (IQR, 27e99), median weight was 20 kg (IQR, 12e30) and median body mass index was 17 (IQR, 15e18). During the 30- day followup period there were 9 complications (6.7%), of which only 1 (0.7%) was high grade (Clavien-Dindo 3). There were 9 emergency room visits (6.7%) including 5 cases of readmission (3.7%). Conclusions: Robotic reconstructive and extirpative procedures in pediatric urology can be safely performed as scheduled outpatient procedures in the majority of patients, obviating the need for routine inpatient care. [ABSTRACT FROM AUTHOR]

Purpose: Our aim was to report the positive surgical margin (PSM) rate of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) in an unselected, real-life cohort of patients treated at a fellowship-training urological department. Materials and Methods: Demographic, clinical and pathological data of 529 consecutive patients who underwent RS-RARP between January 2017 and December 2020 were collected prospectively and analyzed retrospectively in a hospital-approved audit in a European Association of Urology Robotic Urology Section (ERUS)-approved fellowship program. Overall PSM rates were reported for the entire cohort and for pT2 and pT3 patients separately. We defined clinically significant PSM as any length of >3 mm or multiple PSMs regardless of length. Results: Median patient age was 64 years. More than 97% of the patients had intermediate or high-risk disease. The pathological stages were T2 (66.5%) and T3 (33.5%). Overall PSM was reported in 13.3% of pT2 patients and 28.9% of pT3 patients. Clinically significant PSM was reported in 43 patients (8.1%), and most of them (27 patients) had pT3 disease. Only 2.6% positive margins were reported at the apex and 0.7% on the anterior surface and bladder neck. Immediate continence (defined as no pads or 1 safety pad a day) rate was 65%. Conclusions: PSM rates of RS-RARP are acceptable and are higher in pT3 disease compared to pT2. [ABSTRACT FROM AUTHOR]

Purpose: Robot-assisted laparoscopic pyeloplasty (RALP) use in children has increased, though many centers still favor open pyeloplasty (OP) in infants. This study aims to compare safety and efficacy of RALP and OP in infants. Materials and Methods: A single-institution, retrospective cohort study of infants <1 year of age who underwent primary RALP or OP between January 2009 and June 2020 was performed. Primary outcomes were intraoperative and 30-day complications, postoperative radiographic improvement at last clinic visit, and operative failure leading to redo pyeloplasty. Multivariable logistic regression was performed for 30-day complications to adjust for demographic variation between groups. Survival analysis was performed to compare time to diagnosis of operative failure leading to redo pyeloplasty. Results: Among 204 patients, 121 underwent OP and 83 underwent RALP (74.5% male). RALP patients were older (median 7.2 vs 2.9 months, p <0.001) and larger (median 8.2 vs 5.9 kg, p <0.001) than OP patients. Radiographic improvement was seen in 91.1% of RALP patients and 88.8% of OP patients at last visit. Median (interquartile range) followup in months was 24.4 (10.8e50.3) for the full cohort. In adjusted analysis, the odds of a 30-day complication (OR 0.40, 95% CI 0.08e2.00) was lower for RALP compared to OP, though not statistically significant. In survival analysis, there was no difference in time to diagnosis of operative failure and redo pyeloplasty between groups (p=0.65). Conclusions: RALP is a safe and effective alternative to OP for infants, with comparable intraoperative and 30-day complications, radiographic improvement at last followup, and risk of pyeloplasty failure. [ABSTRACT FROM AUTHOR]