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Objective: To evaluate the perioperative complications of single-port robot-assisted radical prostatectomy (SP-RARP)., Patients and Methods: A retrospective review was performed on the prospectively maintained, Institutional Review Board-approved, multi-institutional Single-Port Advanced Research Consortium (SPARC) database. A total of 1103 patients were identified who underwent three different approaches of SP-RARP between 2019 and 2022 using the purpose-built SP robotic platform. In addition to baseline clinical, perioperative outcomes, this study comprehensively analysed for any evidence of intraoperative complication, as well as postoperative complication and readmission within 90 days of the respective surgery., Results: Of the 244, 712, and 147 patients who underwent transperitoneal, extraperitoneal, and transvesical SP-RARP, respectively, intraoperative complications were noted in five patients (0.4%), all of which occurred during the transperitoneal approach. Two patients had bowel serosal tears, two had posterior button-holing of the bladder necessitating repair, and one patient had an obturator nerve injury. Postoperative complications were noted in 143 patients (13%) with major complications (Clavien-Dindo Grade ≥III) only identified in 3.7% of the total cohort. The most common complications were lymphocele (3.9%), acute urinary retention (2%), and urinary tract infection (1.9%). The 90-day re-admission rate was 3.9%., Conclusion: The SP-RARP is a safe and effective procedure with low complication and readmission rates regardless of the approach. These results are comparable to current multi-port RARP literature., (© 2023 BJU International.)

Background: Acute Kidney Injury (AKI) is a common occurrence after partial nephrectomy and is a significant risk factor for chronic kidney disease. We aimed to create a model that predicts postoperative AKI in patients undergoing robot-assisted partial nephrectomy (RAPN)., Methods: We identified 1,190 patients who underwent RAPN between 2008 and 2017 from a multicenter database. AKI was defined as a >25% reduction in eGFR from pre-RAPN to discharge. A nomogram was built based on a binary logistic regression that ultimately included age, sex, BMI, diabetes, baseline eGFR, and RENAL Nephrometry score. Internal validation was performed using the leave-one-out cross validation. Calibration was graphically investigated. The decision curve analysis was used to evaluate the net clinical benefit; a classification tree was used to identify risk categories. The same model was fit adding ischemia time during RAPN., Results: Median (IQR) age at surgery was 61 (50, 68) years; 505 (42%) patients were female, while 685 (58%) were male. Median (IQR) ischemia time during RAPN was 14 (10, 18) min. postoperative AKI occurred in 274 (23%) patients. All variables fitted in the model emerged as predictors of AKI (all P ≤ 0.005) and all were considered to build a nomogram. After internal validation, the area under the curve was 73%. The model demonstrated excellent calibration and improved clinical risk prediction at the decision curve analysis. In the low, intermediate, and high-risk groups the postoperative AKI rates were: 10%, 30%, and 48%, respectively. Adding ischemia time to the preoperative model fit the data better (likelihood ratio test: P < 0.001) and yielded an incremental area under the curve of 3% (95% confidence interval: 1, 5%) CONCLUSION: We developed a nomogram that accurately predicts AKI in patients undergoing RAPN. This model might serve (1) in the preoperative setting: for counsel patients according to their preoperative AKI risk (2) in the immediate postoperative: for identifying patients who would benefit from an early multidisciplinary evaluation, when considering also ischemia time., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To determine the safety and efficacy of performing partial nephrectomy (PN) on patients with high nephrometry score tumors., Patients and Methods: We used a prospectively maintained multi-institutional kidney cancer database to identify 144 patients with R.E.N.A.L. nephrometry score ≥10 who underwent PN for a cT1-cT2 renal mass. Baseline demographics and clinical characteristics, tumor characteristics, perioperative, and pathological outcomes were analyzed and reported. Trifecta achievement, defined by warm ischemia time <25 minutes, no perioperative complications, and negative surgical margins, was the primary outcome. We assessed the relationship of baseline clinical and tumor characteristics data to trifecta achievement and perioperative complications., Results: Baseline median eGFR was 84.57 ml/min/1.73 m 2 , with 119 (84.39%) patients having normal baseline kidney function. The median clinical tumor size was 4.95 cm, with 74 (51.75%) being completely endophytic and 58 (41.73%) located on the hilum. The median ischemia time was 20 minutes. Median estimated blood loss was 150 ml. Twelve patients (8.33%) had intraoperative complications. No patient had a conversion to open surgery. Postoperative, perioperative, and major complication rate were 10.42%, 17.3%, and 2.34% respectively. Thirty-six patients (37.89%) developed postoperative acute kidney injury and 28 (20.90%) developed new-onset CKD at a median follow-up of 6 months. Eight patients (5.56%) had a positive surgical margin. Trifecta was achieved in 89 (61.81%) patients. There was no significant difference in baseline, clinical, and tumor characteristics between those that achieved trifecta and in those where trifecta was not. Pathologic tumor stage was the only factor significantly associated with trifecta achievement (P = 0.025)., Conclusion: In treating complex renal tumors, PN should be performed when possible. Although this remains a challenging procedure, with experience and appropriate case selection, the trifecta outcome can be achieved in a significant number of patients with high renal score lesions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To evaluate outcomes after focal ablative therapy for renal cell carcinoma (RCC) in transplant allograft kidneys., Methods: After institutional review board approval, patients with a history of RCC in a transplanted allograft kidney who underwent focal ablative therapy were identified. Complete chart reviews were performed and the relevant data were extracted for cumulative analysis., Results: Six patients were treated with focal ablative therapy for RCC in a transplanted allograft kidney at our institutional between 2010 and 2017. Masses were diagnosed at a median of 8 years (range 1 month-8 years) after transplantation. Median mass size was 3 cm. Three patients were treated with microwave ablation, 1 with percutaneous irreversible electroporation, 1 with laparoscopic cryoablation, and 1 with open cryoablation. Median follow-up was 45 months (range 8-61 months). The median creatinine level was 1.65 before ablation and 1.58 1 year after ablation. No patients required dialysis after ablation. No patients developed local recurrence during the follow-up period. However, 1 patient developed lymph node metastases 4 years after ablation. Two patients died during follow-up of other causes. At the time of death both patients had functioning grafts., Conclusion: Focal ablative therapies are a feasible, renal-sparing intervention for the management of RCC in renal allografts at intermediate-term follow-up., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: 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., Materials and Methods: 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., Results: 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)., Conclusions: 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., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: Previous robot-assisted partial nephrectomy (RAPN) studies have identified various predictors of overall and major postoperative complications, but few have evaluated the specific role of these factors in the development of medical and surgical complications. In this study, we present an analysis of the modifiable and nonmodifiable variables influencing medical and surgical complications in a contemporary series of patients who underwent RAPN and were followed in a prospectively maintained, multi-institutional kidney cancer database., Methods: A retrospective review of all patients who underwent RAPN at four institutions between 2008 and 2015 was performed. Multivariable logistic regression models were used to determine predictors of medical and surgical postoperative complications., Results: Data from 1139 patients were available for analysis. Sixty-seven patients (5.8%) experienced a medical postoperative complication, and 82 (7.1%) experienced a surgical complication. Decreasing baseline estimated glomerular filtration rate (eGFR) (odds ratio [OR] = 0.98, p = 0.003), greater estimated blood loss (EBL) (OR = 1.002, p = 0.001), and operating surgeon (OR = 8.01, p < 0.001) were associated with an increased likelihood of surgical complications, while decreasing baseline eGFR (OR = 0.99, p = 0.054) and operating surgeon (OR = 1.96, p = 0.054) were associated with an increased likelihood of medical complications., Conclusion: We present complication risks in a large contemporary cohort of patients undergoing robotic partial nephrectomy (RPN) with only 11.3% of patients experiencing a medical or surgical postoperative complication. Prospective candidates for robotic PN with poor baseline renal function and/or risk factors for greater EBL, including a high body mass index, or a complex renal mass should be counseled appropriately on their increased risk for a medical or surgical postoperative complication.

Objective: To investigate the incidence and timing of venous thromboembolism (VTE) and identify risk factors for venous thromboembolism among patients undergoing major surgery for urologic malignancies. VTE events are stratified by occurrence in the inpatient vs outpatient settings., Materials and Methods: The National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Statistical Classification of Diseases, Ninth Revision codes to identify patients undergoing major surgery for urologic malignancies between 2005 and 2012. The incidence of overall 30-day VTE, postdischarge VTE, and post-VTE death was calculated for each surgical procedure. Logistic regression analysis was used to identify risk factors for VTE, adjusting for covariates including age, race, gender, smoking status, medical comorbidities, performance of pelvic lymph node dissection, and operative time., Results: The study identified 27,455 patients who underwent an operation for malignancy--radical nephrectomy, partial nephrectomy, nephroureterectomy, radical prostatectomy, or radical cystectomy. The incidence and timing of VTE varied substantially across the procedures of interest. Overall, VTE occurred after radical cystectomy in 113 of 2065 of patients (5.5%), whereas only 19 of 2624 (0.7%) and 12 of 1690, respectively, of patients undergoing minimally invasive radical or partial nephrectomy procedures suffered a VTE event within 30-days of surgery. Among patients suffering a VTE after radical prostatectomy, 147 of 178 of venous thromboembolic events (82.6%) occurred after hospital discharge., Conclusion: This study demonstrates the significant burden of VTE beyond the time of hospital discharge. Identification of high-risk patients should prompt consideration of extended-duration VTE prophylaxis in the outpatient setting., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: Neurovascular bundle preservation generally results in good postoperative sexual function after radical prostatectomy. However, erectile function (EF) after radical prostatectomy is still a significant concern. The same surgical technique often results in different EF outcomes., Aim: We evaluated factors that correlate with recovery of EF within 1 year after robotic-assisted laparoscopic radical prostatectomy (RALP)., Methods: From January 2008 to May 2009, 145 consecutive patients underwent RALP by one surgeon. Patients were followed postoperatively at 3-month intervals and assessed for EF recovery, defined as an erection sufficient for penetrative intercourse with satisfaction. Baseline demographics, medical comorbidities, degree of nerve sparing, and perioperative and postoperative variables were recorded. Univariate and multivariate analyses were used to determine factors associated with EF recovery., Main Outcome Measures: Postoperative sexual outcomes were attained prospectively via our erectile state questionnaire., Results: Complete follow-up EF data were available on 89 men. Within 1-year follow-up, 56 men (62.9%) recovered EF and 33 men (37.1%) did not. In univariate logistic regression analysis, race (black), diabetes mellitus, hyperlipidemia, and clinical T2 carcinoma of the prostate were associated with diminished EF. Higher-preoperative Sexual Health Inventory for Men score and incremental nerve sparing (enhanced lateral prostatic fascia sparing) were associated with higher odds of recovering potency. In multivariate analysis, hyperlipidemia was primary comorbidity associated with diminished EF, and bilateral nerve sparing with a minimum unilateral-enhanced status was the impacting factor for EF recovery within 1 year after surgery., Conclusions: Bilateral nerve preservation with a minimum unilateral-enhanced status is associated with improved recovery of EF, and hyperlipidemia is a significant negative predictive factor of postoperative EF recovery within 1 year following RALP. Therefore, it is important to control hyperlipidemia as well as to use the proper surgical technique in maximizing EF recovery within 1 year after radical prostatectomy., (© 2011 International Society for Sexual Medicine.)

Study Type: Therapy (case series)., Level of Evidence: 4., Objective: To evaluate factors that affect compliance in men who enroll in a phosphodiesterase type 5 inhibitor (PDE5I) protocol after nerve-sparing robot-assisted prostatectomy (RAP), and report on short-term outcomes, as PDE5Is may help restore erectile function after RAP and patient adherence to the regimen is a factor that potentially can affect outcome., Patient and Methods: We prospectively followed 77 men who had nerve-sparing RAP and enrolled in a postoperative penile rehabilitation protocol. The men received either sildenafil citrate or tadalafil three times weekly. The minimum follow-up was 8 weeks. Potency was defined as erection adequate for penetration and complete intercourse. Compliance was defined as men adhering to the regimen for > or =2 months., Results: The mean age of the cohort was 57.8 years and the median follow-up was 8 months. In all, 32% of the men discontinued the therapy <2 months after RAP and were deemed noncompliant with an additional 39% discontinuing therapy by 6 months, with the high cost of medication being the primary reason (65%). Long-term compliance and preoperative erectile dysfunction were independent predictors of potency return after adjusting for age and nerve sparing., Conclusions: The high cost of medication remains a significant barrier to maintaining therapy. Noncompliance to PDE5I therapy in a tertiary care centre was much higher than reported in clinical trial settings. With longer-term follow-up, we need to further define the factors that improve overall recovery of sexual function after RAP.