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The typical mean length of stay following robot-assisted laparoscopic prostatectomy is 24 to 48 hours. We began routinely offering same day discharge from the hospital after robot-assisted laparoscopic prostatectomy. We evaluated the success rate, safety and cost implications in what is to our knowledge the only large series of same day discharge to date.Beginning in September 2016 all patients were given the option of same day discharge without it being mandated. After allowing 3 months to solidify the protocol we evaluated our prospective database for the next 500 patients.Of the 500 consecutive men who underwent robot-assisted laparoscopic prostatectomy performed by 1 surgeon in 18 months 246 (49.2%) were discharged home the day of surgery and all of the remaining 254 were discharged the next day for a mean 0.51-day length of stay. Mean patient age was 62 years (range 42 to 81) and mean body mass index was 29.7 kg/mSame day discharge following robot-assisted laparoscopic prostatectomy can be safely routinely offered with no increase in readmissions or emergency visits. It may lead to significant savings in health care costs.

We evaluated the predictive value of the ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Program®) surgical risk calculator in a tertiary referral cohort of patients who underwent robot-assisted partial nephrectomy.We queried our prospectively maintained, multi-institutional database of patients treated with robot-assisted partial nephrectomy and input the preoperative details of 300 randomly selected patients into the calculator. Accuracy of the calculator was assessed by the ROC AUC and the Brier score.The observed rate of any complication in our cohort was 14% while the mean predicted rate of any complication using the calculator was 5.42%. The observed rate of serious complications (Clavien score 3 or greater) was 3.67% compared to the predicted rate of 4.89%. Low AUC and high Brier score were calculated for any complication (0.51 and 0.1272) and serious complications (0.55 and 0.0352, respectively). The calculated AUC was low for all outcomes, including venous thromboembolism (0.67), surgical site infection (0.51) and pneumonia (0.44).The ACS NSQIP risk calculator poorly predicted and discriminated which patients would experience complications after robot-assisted partial nephrectomy. These findings suggest the need for a more tailored outcome prediction model to better assist urologists risk stratify patients undergoing robot-assisted partial nephrectomy and counsel them on individual surgical risks.

We describe a technique of complete intracorporeal renal autotransplantation with donor nephrectomy and transplantation performed in a minimally invasive fashion without extracting the kidney.We developed this technique of a completely intracorporeal robotic renal autotransplantation and determined the feasibility of this novel procedure. This includes a method of intracorporeal transarterial hypothermic renal perfusion using a perfusion catheter through a laparoscopic port. The procedure was successfully applied in a 56-year-old man with extensive left ureteral loss after failed ureteroscopy for ureterolithiasis.Robotic donor nephrectomy was performed with a warm ischemia time of 2.3 minutes. Subsequently cold ischemia was achieved by intracorporeal hypothermic renal perfusion for 95.5 minutes. Vascular anastomoses and ureteroureterostomy in the ipsilateral pelvis were completed after donor nephrectomy with a total overall surgeon console time of 334 minutes. Venous and arterial anastomosis times were 17.3 and 21.3 minutes, respectively. Estimated blood loss was less than 50 ml. There were no complications and the patient was discharged home on postoperative day 1 after normal Doppler transplant renal ultrasound. Postoperative renal scan at 6 weeks, intravenous urogram at 8 weeks and computerized tomography urography at 5 months revealed normal function and successful ureteral reconstruction.We report the feasibility of a technique of a completely intracorporeal robotic renal autotransplantation. This operation may be considered in select patients in the hands of experienced robotic surgeons. However, further refinement is required as this novel procedure is cautiously reproduced and adopted by others.

Near infrared fluorescence allows the differentiation of tumors and normal parenchyma during robotic partial nephrectomy. This may facilitate tumor excision but requires proper dosing of indocyanine green. Under dosing causes inadequate fluorescence of peritumor parenchyma. Overdosing causes tumors to fluoresce inappropriately. Currently there are no described dosing strategies to our knowledge to optimize near infrared fluorescence and reported doses vary widely. We devised a dosing strategy and assessed the reliability of near infrared fluorescence for differential fluorescence.Robotic partial nephrectomy with near infrared fluorescence was performed for 79 tumors. Dosing strategy involved at minimum 2 indocyanine green doses, including the test dose and the calibrated dose before resection. The test dose was deliberately low to avoid confounding over-fluorescence. The second dose was calibrated depending on the extent of differential fluorescence achieved with the test doses. Intraoperative assessment of tumor fluorescence was recorded before pathological assessment.Mean tumor size was 3.5 cm (range 1.1 to 9.8) with a mean R.E.N.A.L. score of 8 (range 4 to 12). Median indocyanine green test dose and re-dose before clamping were 1.25 mg (range 0.625 to 2.5) and 1.875 mg (range 0.625 to 5), respectively. Differential fluorescence was achieved in 65 of 79 tumors (82%) that did not fluoresce. After 3 exclusions for the inability to assess fluorescence or indeterminate histology, 60 of 76 tumors were renal cell carcinoma. Of 60 renal cell carcinomas 55 behaved appropriately and did not fluoresce (92%). Overall 65 of 76 tumors behaved appropriately for an 86% agreement between histology and near infrared fluorescence behavior.With our dosing regimen near infrared fluorescence was highly reliable in achieving differential fluorescence of kidney and renal cell carcinomas. Standardized dosing is needed before deciding whether near infrared fluorescence improves robotic partial nephrectomy outcomes and additional studies may further improve reliability.

Drain placement after partial nephrectomy is considered standard but it is based on routine and not on evidence. With experience we performed robotic partial nephrectomy and routinely omitted a drain even with significant collecting system violation. We have rarely used drains after robotic partial nephrectomy for several years, and we report our outcomes.We reviewed a single surgeon, prospective database of all robotic partial nephrectomies from February 2008 to March 2012, including the characteristics of those with and without a drain.The 150 patients underwent a total of 160 robotic partial nephrectomy procedures with a drain used in 11 patients and omitted in 93%. Mean patient age was 57 years (range 22 to 89), mean American Society of Anesthesiologists score was 2.8 (range 2 to 4) and mean body mass index was 32 kg/m(2) (range 18 to 54). Values were similar in patients with and without a drain. In patients without a drain and in those with a drain mean tumor size was 3.5 cm (range 1.0 to 11.0) and 4.6 cm (range 1.1 to 8.6), and mean R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines, hilar tumor touching main renal artery or vein) nephrometry score was 7.8 (range 4 to 12) and 8.8 (range 6 to 11), respectively. Collecting system violation occurred in 88 patients (59%), including 78 without a drain. Two patients (1.3%) required transfusion with no intervention for bleeding. All except 5 patients (97%) were discharged home on postoperative day 1 with all drains removed before discharge. In 2 patients (1.3%) without a drain small urinomas without infection developed more than 2 weeks postoperatively, which were treated with a week of Foley catheter drainage and percutaneous drainage, respectively.Drain placement after robotic partial nephrectomy can be routinely omitted with a low rate of urine leaks, which can be managed safely when they rarely occur.

Discovery of prostatic adenocarcinoma limited to transurethral resection material generates a treatment dilemma. We investigated the usefulness of parameters shown to be associated with prognosis in prostate cancer (p53 and bcl-2 immuno-expression, DNA cell cycle analysis and Gleason score) to stratify these incidentally identified tumors to guide clinical decision making.Paraffin embedded tissues from transurethral prostate resection specimens containing T1a prostate adenocarcinoma from 44 patients who underwent resection between 1980 and 1990 were immunostained for p53 and bcl-2, and subjected to flow cytometry to determine DNA ploidy. Gleason score was determined by 2 pathologists independently. Statistical relationships among these 4 variables, tumor progression and cancer specific survival were analyzed.Six of 44 patients in the study population had cancer progression. Time to clinical progression was 4.5 years (range 7 months to 11 years). Most tumors stained negative for p53 and bcl-2. Only 2 tumors studied were aneuploid and neither of these 2 patients had cancer progression. Only Gleason score was a significant predictor of cancer progression on univariate and multivariate Cox regression analysis (p = 0.045 and 0.046, respectively). No tumor characteristics correlated with time to disease progression, including p53 and bcl-2 immuno-expression, and Gleason score (p = 0.182, 0.563 and 0.346, respectively). Positive immunostaining for p53 and bcl-2 did not occur together in the same tumor in significant fashion (p = 0.334), nor did either significantly occur more with aneuploidy (p = 0.237 and 0.307 respectively).For T1a prostate cancer incidentally detected on transurethral prostate resection p53 and bcl-2 immuno-expression, and DNA ploidy do not predict survival or disease progression.