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To assess the perceptions and outcomes of the A preference signaling (PS) pilot implemented by the Society of Academic Urology in the 2021-2022 Urology Match cycle.Five non-weighted signals were provided to each applicant, and signals were delivered to programs by the American Urological Association to provide an applicant-centered formal and equitable process to express genuine interest in residency programs. Applicant and program perception and behavior was assessed through surveys. Signal distribution, mean, range, and interview offer rates for overall, signaled, and non-signaled programs were calculated.In the 2021-2022 Urology Match cycle, 566 applicants completed signaling; 2829 total signals were sent to programs with 97% applicant and 100% program participation. Each program received a mean number of 19 signals (range of 1-62), and 25% of programs received 49% of all signals. The overall interview-offer rate for the cohort was 12.5% (6019 interviews held/47,989 applications received); the signaled interview rate was 51% (1443/2829), and the non-signaled interview rate was 10% (4576/45,160) with an approximate 4-fold increase in rate of interview for signaled programs compared to non-signaled programs. There was moderate to high levels of satisfaction from applicants and programs on the overall process. 48% of programs incorporated PS into initial application review.Preference signaling was demonstrated to be feasible and successful in providing a novel applicant-directed, formal, equitable, and credible structured process for applicants to express genuine interest in programs. Additionally, programs were able to incorporate PS into their interview selection and recruitment process.

Objectives To conduct a nationwide evaluation of student and program director (PD) perspectives of virtual subinternships that took place during the COVID-19 pandemic. Methods In December 2020, we distributed anonymous surveys to all 534 urology residency applicants and 161 urology PDs at academic medical centers across the United States to evaluate virtual subinternships. Surveys assessed curriculum composition, goals, satisfaction, barriers, and future reusability. The primary outcome was overall satisfaction with the subinternship, evaluated on a 5-point Likert scale. Results The survey was completed by 174 students (33%) and 82 PDs (51%), including 81 students (47%) and 32 PDs (41%) who participated in virtual subinternships at 29 institutions. Overall, 77% of students and 78% of PDs rated the electives "excellent" or "very good." On ordinal logistic regression, higher student ratings were associated with duration ≥3 weeks (OR 4.64, p=0.003) and class size ≤4 students (OR 3.33, p=0.015). Higher PD ratings were associated with full-time electives (OR 11.18, p=0.019), class size ≤4 students (OR 13.99, p=0.042), and utilization of the standardized Guidebook from the Society of Academic Urologists (OR 11.89, p=0.038). The most commonly reported challenge to the subinternship's efficacy was lack of hands-on learning (87% of students and 81% of PDs). Looking forward, 45% of students and 66% of PDs recommended incorporating virtual components into future electives. Conclusions The virtual subinternship was a coordinated nationwide initiative to provide urologic education to medical students during a pandemic. The most successful courses were structured with longer duration, full-time commitment, and small class size.

Objectives To compare perioperative and oncologic outcomes of intracorporeal (ICNB) and extracorporeal neobladder (ECNB) following robot assisted radical cystectomy (RARC) from a multi-institutional, prospectively maintained database, the International Robotic Cystectomy Consortium (IRCC). Methods A retrospective review of IRCC database between 2003 and 2020 (3742 patients from 33 institutions across 14 countries) was performed (I-97906). The Cochran-Armitage trend test was used to assess utilization of ICNB over time. Multivariate logistic regression models were fit to evaluate variables associated with receiving ICNB, overall complications, high-grade complications, and readmissions after RARC. Kaplan Meier curves were used to depict recurrence-free (RFS), disease-specific (DSS), and overall survival (OS). Results 411 patients received neobladder, 64% underwent ICNB. ICNB utilization increased significantly over time (p Conclusion Utilization of ICNB increased significantly over time. Patients who underwent RARC and ICNB had shorter hospital stays and fewer 30-d reoperations but were readmitted more frequently compared to those who underwent ECNB.

To identify trends in complications following robot-assisted radical cystectomy (RARC) using a multi-institutional database, the International Robotic Cystectomy Consortium (IRCC).A retrospective review of the IRCC database was performed (2976 patients, 26 institutions from 11 countries). Postoperative complications were categorized as overall or high grade (≥ Clavien Dindo III) and were further categorized based on type/organ site. Descriptive statistics was used to summarize the data. Multivariate analysis (MVA) was used to identify variables associated with overall and high-grade complications. Cochran-Armitage trend test was used to describe the trend of complications over time.1777 (60%) patients developed postoperative complications following RARC, 51% of complications occurred within 30 days of RARC, 19% between 30-90 days, and 30% after 90 days. 835 patients (28%) experienced high-grade complications. Infectious complications (25%) were the most prevalent, while bleeding (1%) was the least. The incidence of complications was stable between 2002-2021. Gastrointestinal and neurologic postoperative complications increased significantly (P.01, for both) between 2005 and 2020 while thromboembolic (P = .03) and wound complications (P.01) decreased. On MVA, BMI (OR 1.03, 95%CI 1.01-1.05, P.01), prior abdominal surgery (OR 1.26, 95%CI 1.03-1.56, P = .03), receipt of neobladder (OR 1.52, 95%CI 1.17-1.99, P.01), positive nodal disease (OR 1.33, 95%CI 1.05-1.70, P = .02), length of inpatient stay (OR 1.04, 95%CI 1.02-1.05, P.01) and ICU admission (OR 1.67, 95%CI 1.36-2.06, P.01) were associated with high-grade complications.Overall and high-grade complications after RARC remained stable between 2002-2021. GI and neurologic complications increased, while thromboembolic and wound complications decreased.

Coronavirus disease (COVID-19) has profoundly impacted residency training and education. To date, there has not been any broad assessment of urological surgery residency changes and concerns during the COVID-19 pandemic.The Society of Academic Urologists distributed a questionnaire to urology residency program directors on March 30, 2020 exploring residency program changes related to the COVID-19 pandemic. Descriptive statistics are presented. A qualitative analysis of free response questions was undertaken. A post hoc analysis of differences related to local COVID-19 incidence is described.The survey was distributed to 144 residency programs with 65 responses for a 45% response rate. Reserve staffing had started in 80% of programs. Patient contact time had decreased significantly from 4.7 to 2.1 days per week (p0.001). Redeployment was reported by 26% of programs. Sixty percent of programs reported concern that residents will not meet case minimums due to COVID-19. Wellness activities centered on increased communication. All programs had begun to use videoconferencing and the majority planned to continue. Programs in states with a higher incidence of COVID-19 were more likely to report resident redeployment (48% vs 11%, p=0.002) and exposure to COVID-19 positive patients (70% vs 40%, p=0.03), and were less likely to report concerns regarding exposure (78% vs 97%, p=0.02) and personal protective equipment availability (62% vs 89%, p=0.02).As of April 1, 2020 the COVID-19 pandemic had resulted in significant changes in urology residency programs. These findings inform a rapidly changing landscape and aid in the development of best practices.

Background Although pathological factors remain the main determinate of survival for patients with bladder cancer, quality of surgical care is crucial for satisfactory outcomes. Using a validated quality score, we investigated the impact of surgical factors on the overall survival (OS), recurrence-free survival (RFS) and disease-specific survival (DSS) in patients with locally advanced and organ-confined disease (OCD). Retrospective review of IRCC database includes 2460 patients from 29 institutions across 11 countries. The final cohort included 1343 patients who underwent RARCs between 2005 and 2016. Patients with locally advanced disease (LAD) (> pT2 and/or N +) were compared with OCD (≤ pT2/N0). Validated Quality Cystectomy Score (QCS) based on four sets of quality metrics was used to compare surgical performance. Kaplan–Meier method was used to compute RFS, CSS and OS rates. Multivariable stepwise logistic regression was used to evaluate variables associated with RFS, DSS and OS. Results 48% had LAD. When compared to patients with OCD, they received neobladders less frequently (17% vs. 28%, p p = 0.05). Postoperatively, more patients in the LAD group received adjuvant chemotherapy (24% vs. 4%, p p p Conclusion Quality of surgical care can affect disease control and OS in patients with bladder cancer treated with robot-assisted radical cystectomy.

In addition to its established advantages, laparoscopic radical nephrectomy (RN) poses a unique set of challenges over traditional open surgery. In this study, we discuss preoperative considerations and detailed steps for laparoscopic RN. We review the transabdominal approach in detail, including patient positioning, equipment, and port placement in addition to the surgical steps. Intraoperative decisions such as adrenal management, renal preservation, and tumor identification are reviewed. Common complications of laparoscopic renal surgery are also summarized.

INTRODUCTION AND OBJECTIVE: In-person subinternships for visiting medical students were discouraged during the COVID-19 pandemic. The Society of Academic Urologists (SAU) endorsed virtual subinternships in urology (vSIU) and provided all institutions with a standardized vSIU Guidebook containing a structured curriculum and curated resources. We sought to evaluate the successes and limitations of the vSIU at a national level. METHODS: In December 2020, we sent anonymous surveys via email to all medical students who submitted applications to the urology residency match and to all urology residency program directors (PDs) and associate PDs on the SAU email list. Surveys evaluated goals, curriculum composition, satisfaction, and future reusability. Outcomes were evaluated on a 5-point Likert scale. RESULTS: A total of 162 students (30%) and 78 PDs (48%) completed the survey, including 76 students (47%) and 32 PDs (41%) who participated in vSIU at 29 institutions. Of these electives, 66% were 1-2 weeks in duration, 48% were full-time, and 76% utilized the SAU guidebook. Electives consisted of a wide range of curricular elements (Figure). The most important goals for both students and PDs were experiencing/demonstrating program culture and evaluating whether the program/student are a good fit (≥ 50% rated “extremely important”). These goals were achieved by > 80% of students and PDs. Overall, 79% of students and 78% of PDs rated the vSIU “excellent” or “very good.” On multivariable ordinal logistic regression, duration ≥ 3 weeks and class size ≤ 4 students were associated with higher student ratings (p

INTRODUCTION AND OBJECTIVE:We investigated the outcomes of pT0 after robot-assisted radical cystectomy (RARC).METHODS:A retrospective review of the International Robotic Cystectomy Consortium datab...

Purpose: Although MRI/ultrasound fusion has been primarily used to assist in the diagnosis of prostate cancer, this technology can also be used to focally treat localized prostate cancer. We presen...

Radical cystectomy is the gold standard for nonmetastatic muscle invasive bladder cancer and for refractory nonmuscle invasive disease. Compared to open radical cystectomy, robot-assisted radical cystectomy has been shown to provide comparable early oncologic outcomes and improved perioperative outcomes. However, there is a paucity of data on long-term oncologic outcomes and concerns about a higher incidence of local recurrence after robot-assisted radical cystectomy. We report 10-year oncologic outcomes following robot-assisted radical cystectomy using a multinational database.We retrospectively reviewed the prospective International Robotic Cystectomy Consortium database. Consecutive patients who underwent robot-assisted radical cystectomy 10 years ago or earlier were included in analysis. Data were reviewed for demographics, and perioperative, pathological and oncologic outcomes. Kaplan-Meier curves were used to depict recurrence-free, disease specific and overall survival. Multivariate stepwise Cox regression models were applied to identify variables associated with recurrence-free, disease specific and overall survival.We identified 446 patients with a median age of 67 years (IQR 59-76). Of the patients 10% received neoadjuvant chemotherapy, 51% experienced any complication, 23% had high grade complications and 4% died within 3 months of robot-assisted radical cystectomy. Disease was pT3 or greater in 43% of patients and pN+ in 24% while a positive soft tissue surgical margin was observed in 7%. At a median followup of 5 years (IQR 2-10, maximum 14) local and distant recurrence had developed in 15% and 29% of patients, respectively. Ten-year recurrence-free, disease specific and overall survival rates were 59%, 65% and 35%, respectively. Patients with pT3 or greater and pN+ disease showed worse recurrence-free, disease specific and overall survival.Long-term oncologic outcomes, and recurrence rates and patterns after robot-assisted radical cystectomy seem comparable to those in open series. Advanced disease stage and positive surgical margins remain the main determinants of survival after radical cystectomy.

Introduction: Risk assessment for non-organ-confined prostate cancer (PCa) is important in the surgical planning for radical prostatectomy (RP). Perineural invasion (PNI) on prostate biopsy has been associated with adverse pathological outcomes at prostatectomy. Similarly, the identification of suspected extracapsular extension (ECE) on multiparametric magnetic resonance imaging (mpMRI) has been shown to predict non-organ-confined disease. However, no prior study has compared these factors in predicting adverse pathology at prostatectomy. We evaluated mpMRI ECE and prostate biopsy PNI on multivariable analysis to determine their ability to predict pathological stage at time of RP. Methods: We retrospectively investigated the prostatectomy database at our institution to identify men who underwent prostate biopsy with pre-biopsy mpMRI and subsequent RP from 2013–2017. Multivariable regression analysis was performed to compare the association of mpMRI ECE (mECE) and PNI on prostate biopsy on the likelihood of finding pT3 disease on pathology post-prostatectomy. Results: Of a total 454 RP between 2013 and 2017, 191 patients met our inclusion criteria. Stage pT2 and pT3+ were found in 120 (62.8%) and 71 (37.2%) patients, respectively. Patients with mECE had 4.84 cumulative odds of worse pathological stage on RP (p=0.045) compared to PNI on biopsy, which showed cumulative odds of 2.25 (p=0.048). When controlling only for those patients without PNI, mECE was still found to be a significant predictor of pT3 disease at RP (p=0.030). However, in patients without mECE, PNI was not significant (p=0.062). Conclusions: While mECE and biopsy PNI were both associated with worse pathological stage on RP, mECE had significantly higher cumulative odds compared to PNI. The significant predictive ability of mECE adds further clinical value to the use of mpMRI in PCa management. While validation in a larger cohort is required, these factors have important clinical implications with regards to early diagnosis of advanced disease and surgical planning.

Objective To provide real-time assessment and feedback on the competency of urology residents’ surgical skill via mobile applications and examine their feasibility and utility. Materials and methods Two mobile application-based systems (SIMPL and myTIPreport) were sequentially implemented for the case-by-case assessment of residents’ performance of surgical skills at a single institution. Data was collected regarding residents’ perception of their feedback pre- and post-implementation of the applications. Faculty were surveyed after their implementation to determine their feasibility and utility. Results 297 individual evaluations were completed with SIMPL and 822 with myTIPreport over four and eleven months respectively. Post-implementation, residents showed significantly improved perceptions regarding the quantity and personalization of surgical skill feedback (P = .043 and .005 respectively). A majority (75%) of the faculty found the mobile applications feasible to use, an improvement compared to prior methods of resident evaluation, and would recommend continued use. Conclusion This study represents the first documented use of real-time surgical competency assessment in urology. The use of mobile applications to evaluate urology residents’ surgical competency in clinical practice is both feasible and useful. Their use may allow for more individualized surgical skill teaching during training and for the verification of the surgical skills necessary to practice autonomously.

Objective To compare the perioperative outcomes of intracorporeal (ICUD) vs extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy (RARC). Patients and methods We retrospectively reviewed the prospectively maintained International Robotic Cystectomy Consortium (IRCC) database. A total of 972 patients from 28 institutions who underwent RARC were included. Propensity score matching was used to match patients based on age, gender, body mass index (BMI), American Society of Anesthesiologists Score (ASA) score, Charlson Comorbidity Index (CCI) score, prior radiation and abdominal surgery, receipt of neoadjuvant chemotherapy, and clinical staging. Matched cohorts were compared. Multivariate stepwise logistic and linear regression models were fit to evaluate variables associated with receiving ICUD, operating time, 90-day high-grade complications (Clavien-Dindo Classification Grade ≥III), and 90-day readmissions after RARC. Results Utilisation of ICUD increased from 0% in 2005 to 95% in 2018. The ICUD patients had more overall complications (66% vs 58%, P = 0.01) and readmissions (27% vs 17%, P = 0.01), but not high-grade complications (21% vs 24%, P = 0.22). A more recent RC era and ileal conduit diversion were associated with receiving an ICUD. Higher BMI, ASA score ≥3, and receiving a neobladder were associated with longer operating times. Shorter operating time was associated with male gender, older age, ICUD, and centres with a larger annual average RC volume. Longer intensive care unit stay was associated with 90-day high-grade complications. Higher CCI score, prior radiation therapy, neoadjuvant chemotherapy, and ICUD were associated with a higher risk of 90-day readmissions. Conclusions Utilisation of ICUD has increased over the past decade. ICUD was associated with more overall complications and readmissions compared to ECUD, but not high-grade complications.

INTRODUCTION AND OBJECTIVE:There is limited data demonstrating the efficacy of laparoscopic training curricula, such as BLUS (Basic Laparoscopic Urologic Skills), in improving technical skills. Des...

INTRODUCTION AND OBJECTIVE:There have been concerns about higher incidence of local recurrence after robot-assisted radical cystectomy (RARC) compared to its open counterpart. We sought to report a...

INTRODUCTION AND OBJECTIVE:CSATS, a validated crowd sourced Global Evaluative Assessment of Robotic Skills scoring system, is a voluntary robotic surgery technical skills evaluation designed for su...

We evaluated contemporary practice patterns in the management of small renal masses.We identified 52,804 patients in the NCDB (National Cancer Database) who were diagnosed with a small renal mass (4 cm or less) between 2010 and 2014. Utilization trends of active surveillance, ablation and robotic, laparoscopic and open surgical techniques were compared among all comers, elderly patients 75 years old or older and individuals with competing health risks, defined as a Charlson index of 2 or greater. Multivariable logistic regression models were used to assess factors associated with robotic renal surgery and active surveillance.Surgery remained the primary treatment modality across all years studied, performed in 75.0% and 74.2% of cases in 2010 and 2014, respectively. Although increases in active surveillance from 4.8% in 2010 to 6.0% in 2014 (p0.001) and robotic renal surgery (22.1% in 2010 to 39.7% in 2014, p 0.001) were observed, the increase in the proportion of small renal masses treated with robotic partial and radical nephrectomy was greater than that of active surveillance (82.0% and 63.0%, respectively, vs 25.0%). Subgroup analyses in individuals 75 years old or older, or with a Charlson index of 2 or greater likewise revealed preferential increases in robotic surgery vs active surveillance. On multivariable analysis later year of diagnosis was associated with increased performance of robotic renal surgery compared to active surveillance (2014 vs 2010 OR 1.44, 95% CI 1.20-1.72, p0.001) and nonrobotic procedural interventions (2014 vs 2010 OR 2.59, 95% CI 2.30-2.93, p 0.001).Robotic surgical extirpation has outpaced the adoption of active surveillance of small renal masses. This raises concern that the diffusion of robotic technology propagates overtreatment, particularly among elderly and comorbid individuals.

We studied recurrence-free survival after partial vs radical nephrectomy for clinical stage T1 renal cell carcinoma in all patients and in those up staged to pathological stage T3a.We retrospectively reviewed the records of 1,250 patients who underwent partial or radical nephrectomy for clinically localized T1 renal cell carcinoma between 2006 and 2014. Recurrence-free survival was estimated using the Kaplan-Meier method and evaluated as a function of nephrectomy type with the log rank test and Cox models, adjusting for clinical, radiological and pathological characteristics.A total of 86 recurrences (7%) were observed during a median followup of 37 months. No difference in recurrence-free survival between partial and radical nephrectomy was found among all clinical stage T1 renal cell carcinomas. T3a up staging was noted in 140 patients (11%) and recurrent disease was observed in 44 (31.4%) during a median followup of 38 months. Among up staged T3a cases partial nephrectomy was associated with shorter recurrence-free survival compared to radical nephrectomy on univariable analysis (recurrence HR 2.04, 95% CI 1.12-3.68, p = 0.019) and multivariable analysis (recurrence HR 5.39, 95% CI 1.94-14.9, p = 0.001).In a subgroup of patients clinically staged T1 renal cell carcinoma will be pathologically up staged to T3a. Among these patients those who undergo partial nephrectomy appear to have inferior recurrence-free survival relative to those who undergo radical nephrectomy.

Ureteroarterial fistulas (UAFs) are defined as an abnormal communication between one of the major arteries and the ureter. Urologists most frequently encounter iatrogenic fistulas occurring in patients with a history of pelvic extirpative surgery, chronic ureteral catheterization, and history of pelvic radiation. We present two cases of UAFs in patients with no history of prior radiation, who underwent open radical cystectomy and robot-assisted radical cystectomy with intracorporeal ileal conduit. Both patients developed postoperative ureteroileal anastomotic leaks that were managed with indwelling ureteral catheters. Furthermore, both patients were having left-sided UAF after presenting with nonlife threatening gross hematuria, which became brisk and pulsatile during ureteral stent exchange. Endovascular stenting was performed in both patients with resolution of hemorrhage and full recovery. In one patient, nephrostomy tubes were placed and ureteral catheters were removed; the second patient was managed with continued ureteral catheterization without further episodes of hematuria.

To evaluate the oncologic outcomes among a large cohort of octogenarian patients placed on active surveillance for a localized renal mass. We retrospectively reviewed patients ≥80 years of age presenting for asymptomatic, incidentally detected clinically localized stage T1 renal mass between 2006 and 2013 who were followed by active surveillance (AS). The primary endpoint was development of metastatic renal cell carcinoma. Secondary outcomes included intervention-free survival, cancer-specific survival, and overall survival. Eighty-nine octogenarians (median age = 83.4 years) were placed on AS for a median 29.9 months. Median Charlson Comorbidity Index and Katz Index of Independence in Activities of Daily Living scores were 2 and 5, respectively. For all comers, median initial tumor size was 2.4 cm with median growth rate of 0.20 cm/year. Eight (9.0%) patients failed AS due to delayed intervention and three (1.1%) due to systemic progression after median follow-up of 27.8 and 39.9 months, respectively. Two (2.2%) patients in the delayed intervention cohort developed metastasis after treatment. Tumor growth rate was significantly higher among those undergoing intervention versus no intervention (0.60 vs. 0.15 cm/year, P = 0.05) and among patients with systemic progression versus no metastasis (1.28 vs. 0.18 cm/year, P = 0.001). Five-year intervention-free, metastasis-free, cancer-specific, and overall survivals were 90.6, 95.6, 95.6, and 85.7%, respectively. AS represents an effective management strategy in octogenarians given low overall risk of metastasis. Tumor growth kinetics may identify patients at risk of systemic progression in whom treatment should be considered.

Objectives To evaluate appendiceal onlay flap ureteroplasty for repairing complex right proximal and mid-ureteric strictures. Patients and Methods Between August 2006 and August 2012 four women and two men (mean age 34.2 years) underwent right laparoscopic appendiceal onlay flap ureteroplasty. The mean stricture length was 2.5 cm. Stricture formation was secondary to impacted ureteric stones in three patients and failed pyeloplasty for congenital pelvi-ureteric junction obstruction in the remaining three. Each patient had ipsilateral flank pain before surgery. Results The mean operating time, estimated blood loss and hospital stay were 244 min, 175 mL and 3.2 days, respectively. No intra- or peri-operative complications were noted. The objective success rate was 100% (all patients had radiographic and/or endoscopic resolution of their ureteric strictures). The subjective success rate was 66%, (two patients developed recurrent discomfort, which upon exploration was found to be attributable to fibrosis away from the appendiceal onlay graft, where the gonadal vessels crossed the ureter). Both patients with recurrent pain underwent laparoscopic ureterolysis and bladder advancement flap proximal to the appendiceal onlay, which markedly improved one patient's pain but the other patient continued to have discomfort, ultimately resulting in a laparoscopic nephroureterectomy. Conclusions Appendiceal onlay ureteroplasty is a viable treatment option for patients with complex right proximal and mid-ureteric strictures, while minimising the potential morbidity of appendiceal and ileal interposition.

We sought to investigate the prevalence and variables associated with early oncologic failure.We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot-assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot-assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan-Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival.A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38-5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00-6.97, p0.001) and nodal involvement (OR 2.14, 95% CI 1.21-3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p0.001).The incidence of early oncologic failure following robot-assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot-assisted radical cystectomy.

Objective To characterise the surgical feasibility and outcomes of robot-assisted radical cystectomy (RARC) for pathological T4 bladder cancer. Patients and Methods Retrospective evaluation of a prospectively maintained International Radical Cystectomy Consortium database was conducted for 1118 patients who underwent RARC between 2003 and 2012. We dichotomised patients based on pathological stage (≤pT3 vs pT4) and evaluated demographic, operative and pathological variables in relation to morbidity and mortality. Results In all, 1000 ≤pT3 and 118 pT4 patients were evaluated. The pT4 patients were older than the ≤pT3 patients (P = 0.001). The median operating time and blood loss were 386 min and 350 mL vs 396 min and 350 mL for p T4 and ≤pT3, respectively. The complication rate was similar (54% vs 58%; P = 0.64) among ≤pT3 and pT4 patients, respectively. The overall 30- and 90-day mortality rate was 0.4% and 1.8% vs 4.2% and 8.5% for ≤pT3 vs pT4 patients (P < 0.001), respectively. The body mass index (BMI), American Society of Anesthesiology score, length of hospital stay (LOS) >10 days, and 90-day readmission were significantly associated with complications in pT4 patients. Meanwhile, BMI, LOS >10 days, grade 3–5 complications, 90-day readmission, smoking, previous abdominal surgery and neoadjuvant chemotherapy were significantly associated with mortality in pT4 patients. On multivariate analysis, BMI was an independent predictor of complications in pT4 patients, but not for mortality. Conclusions RARC for pT4 bladder cancer is surgically feasible but entails significant morbidity and mortality. BMI was independent predictor of complications in pT4 patients.

Objective To report on a large multi-institutional series of laparoendoscopic single-site (LESS) partial nephrectomy (PN) and analyse renal function and short-term oncological outcomes. Material and Methods We conducted a retrospective analysis of consecutive cases of LESS-PN performed between November 2007 and March 2012 at 11 participating institutions. Demographic data and data on the main peri-operative outcomes and complications were gathered and analysed. Kidney function was evaluated by measuring serum creatinine concentration and estimated glomerular filtration rate (eGFR). Chronic kidney disease was defined in stages for each patient according to the National Kidney Foundation, Kidney Disease Outcomes Quality Initiative. Results A total of 190 cases were included in this analysis. The mean renal tumour size was 2.6 cm, and the mean PADUA score was 7.2. The median operating time was 170 min with a median estimated blood loss of 150 mL. A clampless technique was used in 70 cases (36.8%) and the median warm ischaemia time (WIT) was 16.5 min. PADUA score independently predicted the length of WIT (low vs high score: odds ratio 5.11, CI 1.50–17.41, P = 0.009; intermediate vs high score: odds ratio 5.13, CI 1.56–16.88, P = 0.007). The overall postoperative complication rate was 14.7%. Where a clamping technique was used, a significant increase in serum creatinine concentration and a significant decrease in eGFR were observed postoperatively and at 6 months. On multivariate analysis PADUA score was the only predicting factor. Overall survival rates were 99, 97 and 88% at 12-, 24- and 36-month follow-up, respectively, while disease-free survival rates were 98% at 12-month and 97% at 24- and 36-month follow-up. Conclusion The study showed that LESS-PN is effective in terms of renal function preservation and oncological control at short- and intermediate-term follow-up.

Objective To report an international, multi-institutional series of laparoendoscopic single-site pyeloplasty (LESS-P) with analysis of functional outcomes. Materials and Methods LESS-P cases performed between October 2007 and June 2012 at 7 institutions worldwide per individual institutional protocols, entry criteria, and techniques were included. Patient characteristics, operative indications, perioperative outcomes, and postoperative follow-up were retrospectively collected and analyzed. Results The study included 140 adult patients (age 39.9 ± 15.7 years; body mass index 24.8 ± 4.2 kg/m 2 ; 15% with previous abdominal surgery) who underwent unilateral LESS-P, most of whom (94.3%) had dismembered reconstructions. Mean operative time was 202.1 ± 47 minutes with an estimated blood loss of 61.2 ± 44.6 mL. Robotic laparoendoscopic single-site surgery was applied in 31 patients (22.1%). A single 2-3 mm accessory port was used in 44 patients (31.4%) and a single 5-12 mm accessory port was added in 9 patients (6.4%), whereas 10 patients (7.1%) were converted to conventional multiport laparoscopy. No patients required conversion to open surgery, nor were any intraoperative complications reported. Length of hospitalization was 2.4 ± 1.6 days. The overall 90-day postoperative complication rate was 18.6%, mostly low-grade complications (Clavien I-II). With a mean follow-up of 14.0 ± 10.8 months, 93.4% had resolution of symptoms and 94.4% had radiographic evidence demonstrating resolution of ureteropelvic junction obstruction. Assessment of drainage with diuretic nuclear renal scan provided evidence of improvement in 86.5% of patients on their first postoperative renal scan. Conclusion This study highlights the most comprehensive experience with LESS-P reported to date. Outcome measures parallel those of large published series of conventional laparoscopic pyeloplasty. Despite these encouraging findings, longer follow-up is needed to determine the efficacy and durability of this approach for the treatment of ureteropelvic junction obstruction.

Background Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the surgical trauma associated with conventional laparoscopy. Partial nephrectomy (PN) represents a challenging indication for LESS. Objective To report a large multi-institutional series of LESS-PN and to analyze the predictors of outcomes after LESS-PN. Design, setting, and participants Consecutive cases of LESS-PN done between November 2007 and March 2012 at 11 participating institutions were included in this retrospective analysis. Intervention Each group performed LESS-PN according to its own protocols, entry criteria, and techniques. Outcome measurements and statistical analysis Demographic data, main perioperative outcome parameters, and perioperative complications were gathered and analyzed. A multivariable analysis was used to assess the factors predicting a short (≤20min) warm ischemia time (WIT), the occurrence of postoperative complication of any grade, and a favorable outcome , arbitrarily defined as a combination of the following events: short WIT plus no perioperative complications plus negative surgical margins plus no conversion to open surgery or standard laparoscopy. Results and limitations A total of 190 cases were included in this analysis. Mean renal tumor size was 2.6, and PADUA score 7.2. Median operative time was 170min, with median estimated blood loss (EBL) of 150ml. A clampless technique was adopted in 70 cases (36.8%), and the median WIT was 16.5min. PADUA score independently predicted length of WIT (low vs high score: odds ratio [OR]: 5.11 [95% confidence interval (CI), 1.50–17.41]; p =0.009; intermediate vs high score: OR: 5.13 [95% CI, 1.56–16.88]; p =0.007). The overall postoperative complication rate was 14.7%. The adoption of a robotic LESS technique versus conventional LESS (OR: 20.92 [95% CI, 2.66–164.64]; p =0.003) and the occurrence of lower (≤250ml) EBL (OR: 3.60 [95% CI, 1.35–9.56]; p =0.010) were found to be independent predictors of no postoperative complications of any grade. A favorable outcome was obtained in 83 cases (43.68%). On multivariate analysis, the only predictive factor of a favorable outcome was the PADUA score (low vs high score: OR: 4.99 [95% CI, 1.98–12.59]; p Conclusions LESS-PN can be safely and effectively performed by experienced hands, given a high likelihood of a single additional port. Anatomic tumor characteristics as determined by the PADUA score are independent predictors of a favorable surgical outcome. Thus patients presenting tumors with low PADUA scores represent the best candidates for LESS-PN. The application of a robotic platform is likely to reduce the overall risk of postoperative complications.

Objective To present outcomes of a randomized, patient-blinded controlled trial on Pfannenstiel laparoendoscopic single-site (LESS) vs conventional multiport laparoscopic live donor nephrectomy. Patients and Methods Patients presenting as left kidney donors between January 2009 and November 2011 were randomized to LESS donor nephrectomy (LESS-DN: n = 15) or conventional laparoscopic donor nephrectomy (LDN: n = 14). Patients were blinded to the surgical approach preoperatively and attempts to continue patient blinding postoperatively were made by applying dressings consistent with multiple conventional laparoscopic incisions for all patients. De-identified data related to the operation, peri-operative course and postoperative follow-up were prospectively collected and compared between the two groups with an intention-to-treat analysis. Results There were no significant differences between the groups when comparing operating time, estimated blood loss (EBL), i.v. fluid administration, renal allograft warm ischaemia time (WIT), length of hospital stay (LOS) and total inpatient analgesic requirements. Quantitative pain assessment was not significantly different on postoperative day (POD) #0, however, it was significantly lower in the LESS-DN group, beginning on POD #1 (P < 0.05). The changes in haematocrit and serum creatinine in the two groups were not significantly different, and there were no blood transfusions in either group, nor was there a decline in estimated glomerular filtration rate to

What's known on the subject? and What does the study add? LESS-NU may be an alternative minimally-invasive treatment option for patients eligible to undergo laparoscopic surgery for upper urinary tract urothelial carcinoma. The true benefits of LESS-NU remain to be determined and require randomized control trials in the future. Despite encouraging early findings, clinical trials still are warranted before this procedure is adopted widely, and longer follow-up is needed to determine its oncological durability. Objective To report a large multi-institutional series of laparoendoscopic single-site (LESS) nephroureterectomy (NU). Materials and Methods Data on all cases of LESS-NU performed between 2008 and 2012 at 15 institutions were retrospectively gathered. The main demographic data and perioperative outcomes were analysed. Results The study included 101 patients whose mean (sd) age was 66.4 (9.9) years and mean (sd) body mass index was 24.8 (4) kg/m2, and of whom 29.7% had undergone previous abdominal/pelvic surgery. The mean (sd) operating time was 221.4 (73.7) min, estimated blood loss 231.7 (348.0) mL. A robot-assisted LESS technique was applied in 25.7% of cases. An extra trocar was inserted in 28.7% of cases to complete the procedure. Conversion to open surgery was necessary in three cases (3.0%). There was no bladder cuff excision in 20.8% of cases, and excision was carried out using a variety of techniques in the remaining cases. Six intra-operative complications occurred (5.9%). The mean (sd) length of hospital stay was 6.3 (3.5) days. The overall postoperative complication rate was 10.0%, and most of the complications were low grade (Clavien grades 1 and 2). The mean tumour size was 3.1 (1.9) cm. Pathological staging was pTis in two patients, pTa in 12 patients, pT1 in 42 patients, pT2 in 20 patients, pT3 in 23 patients and pT4 in two patients. Pathological grade was high in 71 and low in 30 patients. At a mean follow-up of 14 months, six patients (5.9%) had died. Disease recurrence (including distant and bladder recurrence) was detected in 22.8% of patients, with a mean time to recurrence of 11.5 months. Conclusions This study reports the largest multi-institutional experience of LESS-NU to date. Peri-operative outcomes mirror those of published standard laparoscopy series. Despite encouraging early findings, longer follow-up is needed to determine the oncological efficacy of the procedure.

What's known on the subject? and What does the study add? Lymph node dissection and it's extend during robot-assisted radical cystectomy varies based on surgeon related factors. This study reports outcomes of robot-assisted extended lymphadenectomy based on surgeon experience in both academic and private practice settings. Objective To evaluate the incidence of, and predictors for, extended lymph node dissection (LND) in patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer, as extendedLND is critical for the treatment of bladder cancer but the role of minimally invasive surgery for extended LND has not been well-defined in a multi-institutional setting. Patients and Methods Used the International Robotic Cystectomy Consortium (IRCC) database. In all, 765 patients who underwent RARC at 17 institutions from 2003 to 2010 were evaluated for receipt of extended LND. Patients were stratified by age, sex, clinical stage, institutional volume, sequential case number, and surgeon volume. Logistic regression analyses were used to correlate variables to the likelihood of undergoing extended LND. Results In all, 445 (58%) patients underwent extended LND. Among all patients, a median (range) of 18 (0–74) LNs were examined. High-volume institutions (≥100 cases) had a higher mean LN yield (23 vs 15, P < 0.001). On univariable analysis, surgeon volume, institutional volume, and sequential case number were associated with likelihood of undergoing extended LND. On multivariable analysis, surgeon volume [odds ratio (OR) 3.46, 95% confidence interval (CI) 2.37–5.06, P < 0.001] and institution volume [OR 2.65, 95% CI 1.47–4.78, P = 0.001) were associated with undergoing extended LND. Conclusions Robot-assisted LND can achieve similar LN yields to those of open LND after RC. High-volume surgeons are more likely to perform extended LND, reflecting a correlation between their growing experience and increased comfort with advanced vascular dissection.