Search

Ability to predict the risk of intraoperative adverse events (IOAEs) for patients undergoing partial nephrectomy (PN) can be of great clinical significance.To develop and internally validate a preoperative nomogram predicting IOAEs for robot-assisted PN (RAPN).In this observational study, data for demographic, preoperative, and postoperative variables for patients who underwent RAPN were extracted from the Vattikuti Collective Quality Initiative (VCQI) database.IOAEs were defined as the occurrence of intraoperative surgical complications, blood transfusion, or conversion to open surgery/radical nephrectomy. Backward stepwise logistic regression analysis was used to identify predictors of IOAEs. The nomogram was validated using bootstrapping, the area under the receiver operating characteristic curve (AUC), and the goodness of fit. Decision curve analysis (DCA) was used to determine the clinical utility of the model.Among the 2114 patients in the study cohort, IOAEs were noted in 158 (7.5%). Multivariable analysis identified five variables as independent predictors of IOAEs: RENAL nephrometry score (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.25); clinical tumor size (OR 1.01, 95% CI 1.001-1.024); PN indication as absolute versus elective (OR 3.9, 95% CI 2.6-5.7) and relative versus elective (OR 4.2, 95% CI 2.2-8); Charlson comorbidity index (OR 1.17, 95% CI 1.05-1.30); and multifocal tumors (OR 8.8, 95% CI 5.4-14.1). A nomogram was developed using these five variables. The model was internally valid on bootstrapping and goodness of fit. The AUC estimated was 0.76 (95% CI 0.72-0.80). DCA revealed that the model was clinically useful at threshold probabilities5%. Limitations include the lack of external validation and selection bias.We developed and internally validated a nomogram predicting IOAEs during RAPN.We developed a preoperative model than can predict complications that might occur during robotic surgery for partial removal of a kidney. Tests showed that our model is fairly accurate and it could be useful in identifying patients with kidney cancer for whom this type of surgery is suitable.

OBJECTIVES To assess and compare peri-operative outcomes of patients undergoing robot-assisted partial nephrectomy (RAPN) for imperative vs elective indications. PATIENT AND METHODS We retrospectively reviewed a multinational database of 3802 adults who underwent RAPN for elective and imperative indications. Laparoscopic or open partial nephrectomy (PN) were excluded. Baseline data for age, gender, body mass index, American Society of Anaesthesiologists score and PADUA score were examined. Patients undergoing RAPN for an imperative indication were matched to those having surgery for an elective indication using propensity scores in a 1:3 ratio. Primary outcomes included organ ischaemic time, operating time, estimated blood loss (EBL), rate of blood transfusions, Clavien-Dindo complications, conversion to radical nephrectomy (RN) and positive surgical margin (PSM) status. RESULTS After propensity-score matching for baseline variables, a total of 304 patients (76 imperative vs 228 elective indications) were included in the final analysis. No significant differences were found between groups for ischaemia time (19.9 vs 19.8 min; P = 0.94), operating time (186 vs 180 min; P = 0.55), EBL (217 vs 190 mL; P = 0.43), rate of blood transfusions (2.7% vs 3.7%; P = 0.51), or Clavien-Dindo complications (P = 0.31). A 38.6% (SD 47.9) decrease in Day-1 postoperative estimated glomerular filtration rate was observed in the imperative indication group and an 11.3% (SD 45.1) decrease was observed in the elective indication group (P

BACKGROUND: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. Such delays can lead to disease progression. OBJECTIVE: We aimed to develop guidance on criteria for prioritization for surgery and reconfiguring management pathways for non-metastatic stage of prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve low likelihood of COVID-19 hazard if radical prostatectomy was to be carried out during the outbreak and whilst the disease is endemic. DESIGN, SETTING AND PARTICIPANTS: An accelerated consensus process and systematic review. We conducted a systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n=34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. OUTCOME MEASURES: Consensus opinion was defined as ≥80% agreement, which were used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and develop measures to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritization criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as "COVID-19 cold sites". CONCLUSION: Re-configuring management pathways for prostate cancer patients is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing radical prostatectomy within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

Introduction: Minimal invasive surgeries (MIS) for large size adrenal tumors are still debatable. The objective is to evaluate the contemporary peri- and post-operative outcomes of patients undergoing (open = OA, laparoscopic = LA, and robotic = RA) adrenalectomies in three institutions. Materials and methods: Retrospectively gathered peri- and post-operative data of 235 patients, underwent adrenalectomy at three Institutions over a 7-year period (2013–2020) were analyzed. All patients underwent thorough radiological and endocrine workup. Results: Two hundred and thirty five patients who underwent adrenalectomy (OA ( n = 29), LA ( n = 146), and RA ( n = 60)) were assessed. OA ( n = 29) versus Minimally invasive surgery ( n = 206) showed significant differences (median, p value) in larger tumour size, cm (9.4 vs 5, ( p = 0.0001)), longer operative time, mins (240 vs 100, ( p = 0.0001)), longer hospital stay, days (8 vs 3,( p = .0001)), Higher readmission rates (14% vs 1.9%), higher blood loss, ml (400 vs 100, ( p = 0.0001)) requiring blood transfusion (14% vs 4.3%) ( p = 0.03), higher intraoperative complication (21% vs 6%) ( p = 0.0004), and post op complications (17% vs 5.3%) ( p = 0.01). Amongst the MIS (RA vs LA), RA appeared be have better outcomes in terms of shorter operative time, less blood loss and less intra operative complications with a p value Conclusions: Contemporary practice of adrenalectomy shows that robotic adrenalectomy is safe and effective irrespective of the tumor size.

Objective To predict intra-operative (IOEs) and postoperative events (POEs) consequential to the derailment of the ideal clinical course of patient recovery. Materials and methods The Vattikuti Collective Quality Initiative is a multi-institutional dataset of patients who underwent robot-assisted partial nephectomy for kidney tumours. Machine-learning (ML) models were constructed to predict IOEs and POEs using logistic regression, random forest and neural networks. The models to predict IOEs used patient demographics and preoperative data. In addition to these, intra-operative data were used to predict POEs. Performance on the test dataset was assessed using area under the receiver-operating characteristic curve (AUC-ROC) and area under the precision-recall curve (PR-AUC). Results The rates of IOEs and POEs were 5.62% and 20.98%, respectively. Models for predicting IOEs were constructed using data from 1690 patients and 38 variables; the best model had an AUC-ROC of 0.858 (95% confidence interval [CI] 0.762, 0.936) and a PR-AUC of 0.590 (95% CI 0.400, 0.759). Models for predicting POEs were trained using data from 1406 patients and 59 variables; the best model had an AUC-ROC of 0.875 (95% CI 0.834, 0.913) and a PR-AUC 0.706 (95% CI, 0.610, 0.790). Conclusions The performance of the ML models in the present study was encouraging. Further validation in a multi-institutional clinical setting with larger datasets would be necessary to establish their clinical value. ML models can be used to predict significant events during and after surgery with good accuracy, paving the way for application in clinical practice to predict and intervene at an opportune time to avert complications and improve patient outcomes.

We present our study, done to identify the diagnostic yield of cognitive targeted biopsy using mpMRI data, to diagnose clinically significant prostate cancers, in a cohort of biopsy and treatment naive men.This is a prospective, single institutional study, done from September 2018 to March 2020 in 75 biopsy naive men. The patients with 3, 4 and 5 PIRADS scores underwent mpMRI cognitive target biopsy (mpMRI CTB) followed by standard biopsy (SB) in the same setting by two different urologists. Diagnostic yield of biopsy cores, complications, and stage migration of Gleason's grades was analyzed.Out of 75 patients, 34.6% had abnormal digital rectal examination (DRE), and the median serum PSA was 10.6 (4.5-20) ng/mL. Total MRI suspicious lesions were 163. Out of 1263 SB cores, 371 cores were positive for cancer (29.35%), and out of 326 mpMRI CTB cores, 120 were positive for cancer (36.8%) (P0.0001). Histopathological examination (HPE) revealed 88%, 92%, and 100% clinically significant cancers in PIRADS 3, 4 and 5 lesions. SB and mpMRI CTB in combination have better cancer detection yield than either of the modality when used alone (P-0.0001). Clavien-Dindo grade 1 and grade 4a complication were seen in 47 (62.6%) and three (4%) patients.In biopsy-naive men with suspected prostate cancer and equivocal DRE, the addition of pre-biopsy mpMRI detects greater numbers of people with clinically significant prostate cancer when compared with SB alone. Combining SB with mpMRI CTB has a superior diagnosing ability when compared with either of the biopsy modalities when used alone.

Mathisekaran Thangarasu, Sanjay Prakash Jayaprakash, Nivash Selvaraj, Sandeep Bafna, Rajesh Paul, Chandranathan Mahesh, Nitesh Jain, Arunkumar Balakrishnan, Ananthakrishnan Sivaraman Department of Urology, Apollo Main Hospital, Chennai, Tamil Nadu, IndiaCorrespondence: Mathisekaran ThangarasuDepartment of Urology, Apollo Main Hospital, 21 Gream’s Lane, off Gream’s Road, Chennai, 600006, Tamil Nadu, IndiaEmail mathisekaran@gmail.comPurpose: We present our study, done to identify the diagnostic yield of cognitive targeted biopsy using mpMRI data, to diagnose clinically significant prostate cancers, in a cohort of biopsy and treatment naive men.Materials and Methods: This is a prospective, single institutional study, done from September 2018 to March 2020 in 75 biopsy naive men. The patients with 3, 4 and 5 PIRADS scores underwent mpMRI cognitive target biopsy (mpMRI CTB) followed by standard biopsy (SB) in the same setting by two different urologists. Diagnostic yield of biopsy cores, complications, and stage migration of Gleason’s grades was analyzed.Results: Out of 75 patients, 34.6% had abnormal digital rectal examination (DRE), and the median serum PSA was 10.6 (4.5– 20) ng/mL. Total MRI suspicious lesions were 163. Out of 1263 SB cores, 371 cores were positive for cancer (29.35%), and out of 326 mpMRI CTB cores, 120 were positive for cancer (36.8%) (P< 0.0001). Histopathological examination (HPE) revealed 88%, 92%, and 100% clinically significant cancers in PIRADS 3, 4 and 5 lesions. SB and mpMRI CTB in combination have better cancer detection yield than either of the modality when used alone (P-< 0.0001). Clavien-Dindo grade 1 and grade 4a complication were seen in 47 (62.6%) and three (4%) patients.Conclusion: In biopsy-naive men with suspected prostate cancer and equivocal DRE, the addition of pre-biopsy mpMRI detects greater numbers of people with clinically significant prostate cancer when compared with SB alone. Combining SB with mpMRI CTB has a superior diagnosing ability when compared with either of the biopsy modalities when used alone.Keywords: mpMRI target biopsy, prostate cancer, standard systematic biopsy, cognitive targeted biopsy

The objective of the study is to describe the perioperative outcomes, disease-specific, and overall survival status in patients diagnosed with renal cell carcinoma with inferior vena cava (IVC) tumor thrombus.We did a retrospective analysis of all patients who underwent radical nephrectomy along with IVC thrombectomy from the year 2013 to 2020. Mayo's classification was used to stratify the level of IVC thrombus. Demographic, perioperative, histopathology data, complications, and survival status were analyzed.Total number of patients included in the study was 39, (Male: Female = 84.6%: 15.4%). Median age of patients was 58 (interquartile range [IQR] 50-63) years. Median size of renal tumor (in cms) was 9.5 (IQR 7.5-12), 8 (IQR 7-11.5), 8.5 (IQR 7-11.75), and 11 (IQR 9.5-11) (The tumor size does not have an influence on the progression of tumor thrombus into IVC. Significant difference in survival was observed between different levels of thrombus with high mortality in level four tumors.

OBJECTIVES: To analyze the outcomes of patients in whom cortical (outer) renorrhaphy (CR) was omitted during robotic partial nephrectomy (RPN). METHODS: We analyzed 1453 patients undergoing RPN, from 2006 to 2018, within a large multi-institutional database. Patients having surgery for bilateral tumors (n = 73) were excluded. CR and no-CR groups were compared in terms of operative and ischemia time, estimated blood loss (EBL), complications, surgical margins, hospital stay, change in estimated glomerular filtration rate (eGFR), and need of angioembolization. Inverse probability of treatment weighting with Firth correction for center code was performed to account for selection bias. RESULTS: CR was omitted in 120 patients (8.7%); 1260 (91.3%) patients underwent both inner layer and CR. There was no difference in intraoperative complications (7.4% CR; 8.9% no-CR group; P = .6), postoperative major complications (1% and 2.8% in CR and no-CR groups, respectively; P = .2), or median drop in eGFR (7.3 vs 10.4 mL/min/m2). The no-CR group had a higher incidence of minor complications (26.7% vs 5.5% in CR group; P < .001). EBL was 100 mL (IQR 50-200) in both groups (P = .6). Angioembolization was needed in 0.7% patients in CR vs 1.4% in no-CR group (P = .4). Additionally, there was no difference in median operative time (168 vs 162 min; P = .2) or ischemia time (18 vs 17 min; P = .7). CONCLUSION: In selected patients with renal masses, single layer renorrhaphy does not significantly improve operative time, ischemia time, or eGFR after RPN. There is a higher incidence of minor complications, but not major perioperative complications after no-CR technique.

Resumen Introduccion La reaccion inflamatoria local despues de una biopsia prostatica (BP) puede influir de manera negativa en los resultados globales posprostatectomia radical. No hay evidencia suficiente en la literatura respecto al impacto del numero de punciones en los resultados posquirurgicos. Objetivos Determinar el impacto del numero de punciones de la BP en las complicaciones posquirurgicas y en el estado de los margenes operatorios. Material y metodos Se registraron prospectivamente 2.054 pacientes sometidos a prostatectomia radical asistida por robot (PRAR) en nuestra institucion. Se formaron 2 grupos de pacientes, en relacion con el numero de punciones en la BP (G1 ≤ 12 punciones; G2 > 12 punciones). Se evaluo por medio del analisis multivariable (modelos de regresion logistica) el impacto del numero de punciones en las complicaciones posquirurgicas. Resultados Se incluyeron 1.042 pacientes en el grupo 1 (≤ 12 punciones) y 1.012 pacientes en el grupo 2 (> 12 punciones). La tasa de complicaciones perioperatorias se incremento a medida que aumentaba el numero de punciones. (G1 6,4 vs. G2 8,5%; p = 0,03); no obstante, las complicaciones mayores (Clavien 3-4) fueron similares (G1 1,4 vs. G2 2,2%; p = 0,16). No hubo diferencia estadisticamente significativa respecto a los margenes quirurgicos positivos en ambos grupos (G1 11,8 vs. 9,98%; p = 0,2). El analisis multivariable (regresion logistica) demostro que el grupo 2 tenia un porcentaje un 39% mayor de experimentar complicaciones post-PRAR (OR 0,645). Conclusion El mayor numero de punciones (> 12) en la BP podria estar relacionado con mayor sangrado y complicaciones posquirurgicas despues de PRAR. Una cuidadosa evaluacion preoperatoria de los pacientes que se sometieron a biopsias o protocolos de saturacion multiple es obligatoria. La aplicacion de intervalos mas largos (> 6 semanas) entre la biopsia y la cirugia puede ser recomendable para minimizar los potenciales riesgos de complicaciones quirurgicas en los pacientes que pueden beneficiarse de PRAR. Otros estudios son todavia necesarios para confirmar estos resultados.

INTRODUCTION AND OBJECTIVES:The technique of renal reconstruction after robotic partial nephrectomy (RPN) is a modifiable factor with a possible impact on ischemia time, postoperative bleeding, ren...

Resumen Objetivos Reportamos nuestra experiencia inicial en el tratamiento del cancer de prostata (PCa) con ultrasonido focalizado de alta intensidad (HIFU) utilizando el dispositivo Focal-One®. Material y metodos Estudio retrospectivo de datos recogidos prospectivamente. Entre junio de 2014 y octubre de 2015, 85 pacientes recibieron tratamiento HIFU (focal/total), para PCa localizado. La localizacion preoperatoria del tumor fue realizada con resonancia magnetica multiparametrica (mpMRI) y biopsias prostaticas mediante mapeo transperineal. El tratamiento fue realizado utilizando el dispositivo Focal-One® bajo anestesia general. Seguimiento oncologico: medicion del PSA y biopsia control con mpMRI segun protocolo. Los resultados funcionales fueron evaluados mediante cuestionarios validados y las complicaciones reportadas utilizando la clasificacion Clavien. Resultados La mediana de PSA fue 7,79 ng/ml (6,32-9,16) con una mediana de volumen prostatico de 38 cc (33-49,75). El tratamiento fue focal y total en 64 y 21 pacientes respectivamente. Diez pacientes recibieron tratamiento de rescate. La tasa de complicaciones fue del 15%, todas Clavien 2. La estancia hospitalaria media fue 1,8 dias (0-7) y la sonda vesical fue retirada el dia 2 (1-6). La media de reduccion porcentual del PSA fue 54%. La mediana de seguimiento fue 3 meses (2-8). Resultados funcionales: todos los pacientes estuvieron continentes a los 3 meses y la potencia se mantuvo en el 83% de los previamente potentes. Conclusiones El tratamiento HIFU Focal-One® es un procedimiento seguro con pocas complicaciones. Los resultados funcionales no reportan casos de incontinencia y la funcion sexual se mantuvo en el 83%.

Objectives To evaluate the role of transperineal template guided mapping biopsy (TTMB) in determining the management strategy in patients with low risk prostate cancer (PCa). Methods We retrospectively evaluated 169 patients who underwent TTMB at our institution from February 2008 to June 2011. Ninety eight of them harbored indolent PCa defined as: Prostate Specific Antigen

Resumen Objetivos Evaluar el papel de la biopsia de mapeo guiada por plantilla transperineal (TTMB) en la determinacion de la estrategia de manejo en pacientes con cancer de prostata (CaP) de bajo riesgo. Metodos Evaluamos retrospectivamente 169 pacientes que se sometieron a TTMB en nuestra institucion entre febrero de 2008 y junio de 2011. Noventa y ocho de ellos albergaban CaP indolente definido como: antigeno prostatico especifico Resultados TTMB detecto el cancer en 64 (65%) pacientes. La clasificacion al alza y estadidificacion al alza se observaron en el 33% (n = 21), 12% (n = 8) y 7% (n = 5), respectivamente, de los canceres detectados. Las caracteristicas de la enfermedad fueron similares a la ETR inicial en 30 (48%) pacientes y TTMB fue negativa en 34 (35%) pacientes. El volumen de la prostata fue significativamente menor en los pacientes con clasificacion al alza y/o estadificacion al alza observado en TTMB (45,4 vs 37,9; p = 0,03). Los resultados de TTMB influenciaron en el 73,5% de los pacientes clasificacion al alza y/o estadificacion al alza para recibir tratamiento radical, mientras que el 81% de los pacientes con estadio y/o grado sin modificar continuaron la vigilancia activa o terapia focal. Conclusiones En los pacientes con CaP de bajo riesgo diagnosticados por ETR, una posterior TTMB demostro clasificacion al alza y/o estadificacion al alza en aproximadamente un tercio de los pacientes, y dio lugar a un cambio final en la decision de tratamiento.

Background The technique of prostate biopsy has evolved a long way since its inception to being a safe diagnostic procedure. The principles of the biopsy technique continue to improvise with the knowledge about prostate cancer and availability of newer treatment options like active surveillance and focal therapy. Currently, we depend on accurate cancer information from the biopsy more than ever for deciding the ideal treatment option. Aim The aim of this review is to present the major milestones in prostate biopsy technique evolutions and its impact on the prostate cancer management. Acquisition of evidence We performed a detailed non-systematic literature review to present the historical facts on the transformations in prostate biopsy techniques and also the direction of present research to improve accurate cancer detection. Summary of evidence There is a clear change in trend in biopsy technique before and after the introduction of transrectal ultrasound and prostate specific antigen. In the earlier era, the biopsies were aimed at palpable nodules and obtaining adequate prostatic tissue for diagnosis while the later era has moved toward detection of non-palpable and early prostate cancer. Recently, there is an increasing trend toward image guided targeted biopsies to extract maximum cancer information from minimum biopsy cores. Conclusion Prostate biopsy techniques have seen major changes since its inception and have a major impact on prostate cancer management. There is a great potential for research which can further support the newer treatment options like focal therapy.

Resumen Antecedentes La tecnica de la biopsia de prostata ha evolucionado mucho desde sus inicios hasta ser un procedimiento de diagnostico seguro. Los principios de la tecnica de biopsia siguen mejorando con el conocimiento sobre el cancer de prostata y la disponibilidad de opciones de tratamiento mas nuevas, como la vigilancia activa y la terapia focal. Actualmente, dependemos de informacion mas exacta sobre el cancer de la biopsia que nunca para decidir la opcion de tratamiento ideal. Objetivo El objetivo de esta revision es presentar los principales hitos en la evolucion de la tecnica de la biopsia de prostata y su impacto en el manejo del cancer de prostata. Adquisicion de la evidencia Se realizo una revision bibliografica no sistematica detallada para presentar los hechos historicos sobre las transformaciones en las tecnicas de biopsia de prostata y tambien la direccion de la actual investigacion para mejorar la deteccion del cancer precisa. Resumen de la evidencia Hay un claro cambio de tendencia en la tecnica de biopsia antes y despues de la introduccion de la ecografia transrectal y el antigeno prostatico especifico. En la epoca anterior, las biopsias fueron dirigidas a los nodulos palpables y a la obtencion de tejido prostatico adecuado para el diagnostico, mientras que la epoca posterior se ha desplazado hacia la deteccion del cancer de prostata no palpable y temprano. Recientemente, existe una tendencia creciente hacia biopsias dirigidas guiadas por imagen para extraer el maximo de informacion del cancer a partir de nucleos de biopsia minimos. Conclusion Las tecnicas de biopsia de prostata han visto grandes cambios desde su creacion y tienen un impacto importante en el manejo del el cancer de prostata. Hay un gran potencial para la investigacion que puede apoyar aun mas las opciones de tratamiento mas nuevas, como la terapia focal.

Resumen Contexto La cirugia robotica evoluciona rapidamente y se ha convertido en una parte esencial de la practica quirurgica en diversas partes del mundo. En el futuro la tecnologia robotica se expandira globalmente y la mayoria de los cirujanos en todo el mundo tendran acceso a robots quirurgicos. Es fundamental que nos mantengamos al dia en cuanto a los resultados de los procedimientos quirurgicos asistidos por robots, lo que permitira a todos desarrollar una opinion imparcial sobre la utilidad clinica de esta innovacion. Objetivo El objetivo de esta revision es presentar la evolucion, una evaluacion objetiva de los resultados clinicos y las perspectivas futuras de las cirugias urologicas asistidas por robot. Adquisicion de la evidencia Se llevo a cabo una revision bibliografica sistematica de los resultados clinicos de las cirugias urologicas roboticas en PubMed. Se incluyeron ensayos controlados aleatorios, estudios de cohortes y revisiones de articulos. Ademas, se realizo una busqueda detallada en el buscador de la web para obtener informacion sobre la evolucion y las tecnologias en desarrollo en robotica. Sintesis de la evidencia La evidencia actual sugiere que los resultados clinicos de las cirugias urologicas asistidas por robot son comparables a los resultados de cirugias convencionales abiertas y laparoscopicas, y se asocian con menos complicaciones. Sin embargo, no se dispone de resultados a largo plazo de todas las cirugias urologicas roboticas comunes. Son muchos los desarrollos innovadores en robotica que estaran disponibles para el uso clinico en un futuro cercano. Conclusion La cirugia urologica robotica continuara evolucionando en el futuro. Deberiamos seguir analizando criticamente si los avances en tecnologia y el mayor coste se traducen finalmente en un mejor rendimiento quirurgico global y en mejores resultados.

Context Robotic surgery is rapidly evolving and has become an essential part of surgical practice in several parts of the world. Robotic technology will expand globally and most of the surgeons around the world will have access to surgical robots in the future. It is essential that we are updated about the outcomes of robot assisted surgeries which will allow everyone to develop an unbiased opinion on the clinical utility of this innovation. Objective In this review we aim to present the evolution, objective evaluation of clinical outcomes and future perspectives of robot assisted urologic surgeries. Acquisition of evidence A systematic literature review of clinical outcomes of robotic urological surgeries was made in the PUBMED. Randomized control trials, cohort studies and review articles were included. Moreover, a detailed search in the web based search engine was made to acquire information on evolution and evolving technologies in robotics. Synthesis of evidence The present evidence suggests that the clinical outcomes of the robot assisted urologic surgeries are comparable to the conventional open surgical and laparoscopic results and are associated with fewer complications. However, long term results are not available for all the common robotic urologic surgeries. There are plenty of novel developments in robotics to be available for clinical use in the future. Conclusion Robotic urologic surgery will continue to evolve in the future. We should continue to critically analyze whether the advances in technology and the higher cost eventually translates to improved overall surgical performance and outcomes.

Laparoscopic donor nephrectomy (LDN) is today considered the standard of care for live kidney harvest in transplantations. Generally those who are considered fit for an open donor nephrectomy will be able to withstand the surgery by laparoscopy. Traditionally right-sided donor kidney, multiple vessels, vessel anomalies and obesity have been considered as relative contraindications; however, with growing skills and practices, they have been rendered obsolete. In this chapter, we emphasize on the different methods of hilar control. We highlight the techniques, difficulties in hilar control and ways to increase the vein length particularly on the right side.

Since the introduction of da Vinci robotic system (Intuitive Surgicals, Sunnyvale, CA, United States) in 1998, robot assisted laparoscopic surgery (RALS) has expanded its application in Urological practice with promising results. The technical advantages of RALS over pure laparoscopy are magnified (up to ten times) 3D vision, wristed instruments (robotic arms provide 7 degrees of movement as compared to 4 degrees of movement with laparoscopic instruments), tremor filtration and an ergonomic operation set-up which ultimately transform into safer operative procedure and so better patient outcomes.

Introduction The local inflammatory process after prostate biopsies can have a negative impact on functional outcomes of radical prostatectomy. There is no evidence in literature demonstrating its impact on radical prostatectomy. Objectives To evaluate the impact of the number of TRUS core biopsies in the surgical morbidity and rate of positive margin on robot assisted radical prostatectomy (RARP). Material and methods A prospectively maintained database of 2054 RARPs in a single institution. Patients were further grouped into 2 groups based on the number of TRUS biopsy cores (G1 ≤ 12 cores; G2 > 12 cores). Multivariable logistic regression model was applied to analyze the impact of number of cores on complications. Results A total number of 1042 patients in the group 1 (≤12 cores) and 1012 patients in the group 2 (>12 cores) were included. The rate of perioperative complications increased with higher number of biopsies (G1 6.4 vs. G2 8.5%; p = 0.03), but high grade complication (Clavien 3–4) were similar (G1 1.4 vs. G2 2.2%; p = 0.16). Positive surgical margin rates were similar in both groups (G1 11.8 vs. 9.98%; p = 0.2). At the multivariable logistic regression analysis shown that G2 had a 39% (OR 0.645) higher rate to experience perioperative complications during RARP. Conclusion Higher number of TRUS biopsy cores (>12) is associated to higher blood loss and perioperative complications during RARP. Careful preoperative evaluation for those patients underwent multiple biopsies or saturation protocols is mandatory. Application of longer intervals (>6 weeks) between biopsy and surgery may be advisable to minimize potential risks of surgical complications in patients may benefit from RARP. Further studies are still necessary to confirm these results.

Because of the lack of intraoperative visual cues, the amount of nerve sparing (NS) intended by the surgeon does not always correspond to what is actually performed during surgery.Describe a standardized NS grading system based on intraoperative visual cues.A total of 133 consecutive patients who underwent robot-assisted radical prostatectomy (RARP) by a single surgeon were evaluated. The surgeon intraoperatively graded the NS independently for either side as follows: 1=no NS; 2=50% NS; 3=50% NS; 4=75% NS; 5= ≥ 95% NS.RARP; detailed description of a five-point NS grading system.The area of residual nerve tissue on prostatectomy specimens was compared with the intraoperative NS score (NSS). The rate of positive surgical margins (PSMs) according to the NSS is also reported.In all, 52.6% of operated sides (140 of 266 sides) had NSS 5, 30.1% (80 of 266) had NSS 4, 2.3% (6 of 266) had NSS 3, 13.2% (35 of 266) had NSS 2, and 1.9% (5 of 266) had NSS 1. The area of residual nerve tissue was significantly different among the different NSSs: median area (interquartile range) for NSS 5: 0.5 (0-2) mm(2); for NSS 4: 3 (0-8) mm(2); for NSS 3: 13 (7-23) mm(2); for NSS 2: 14 (8-24) mm(2); and for NSS 1: 57 (56-165) mm(2) (p0.001). Overall, 9.02% of the patients (12 of 133 patients) had a PSM, with 8.3% (9 of 108) for pT2 and 12% (3 of 25) for pT3. Side-specific PSMs according to NSS were 3.6% (5 of 140) for NSS 5, 7.5% (6 of 80) for NSS 4, 16.7% (1 of 6) for NSS 3, 5.7% (2 of 35) for NSS 2, and 0% (0 of 5) for NSS 1. A limitation of our study is that the key anatomic landmarks are not recognizable in every case, and this technique might not be easy to perform during the early learning curve.We believe that the visual cues exposed in this article will help surgeons achieve more consistent NS during RARP.

To demonstrate the existence of different degrees of nerve sparing (NS) (graded NS) by comparing the surgeon's intent of NS with the residual nerve tissue on prostatectomy specimens.We performed a prospective study of 133 consecutive patients who underwent robot-assisted radical prostatectomy in January and February of 2011. The surgeon graded the amount of NS intraoperatively independently for either side as follows: 1, no NS; 2,50% NS; 3, 50% NS; 4, 75% NS; and 5, ≥ 95% NS. A pathologist who was unaware of the surgeon's score measured the area of residual nerve tissue on the posterolateral surface of the prostate.A greater NS score correlated significantly with a decreasing area of residual nerve tissue on the prostatectomy specimens (P.001). Overall, the area of residual nerve tissue on the prostatectomy specimens was significantly different among the NS groups (P.001). On specific intergroup analysis, significant differences were found in the area of residual nerve tissue on the prostatectomy specimens between the greater NS groups: NS score 3 versus 4, median 13 mm(2) (interquartile range [IQR] 7-23) versus 3 mm(2) (IQR 0-8; P = .01); NS score 4 versus 5, median 3 mm(2) (IQR 0-8) versus 0.5 mm(2) (IQR 0-2; P = .001).Subjective NS classification using the surgeon's intraoperative perception correlated significantly with the area of residual nerve tissue on the prostatectomy specimens determined by the pathologist. It is possible to intentionally tailor the amount of NS performed at surgery. This finding demonstrates that NS is a graded rather than an all-or-none phenomenon that can even go beyond the traditional concept of complete, partial, or no NS.

In this study we identified preoperative or intraoperative factors responsible for the early return of continence after robot-assisted radical prostatectomy using data from a high volume center.Data from 1,299 patients who underwent robot-assisted radical prostatectomy performed by a single surgeon from January 2008 to June 2010 were collected prospectively and analyzed retrospectively. Patients were categorized according to whether they regained continence (no pad and no urinary leakage) within 3 months and variables were then compared. A self-administered validated questionnaire (Expanded Prostate Cancer Index Composite) was used for assessment of continence status and time to recovery.Within 3 months after surgery 86.3% of patients (1,121/1,299) had recovered continence. Multivariable Cox regression analysis revealed that only age (p0.001, hazard ratio 0.98, 95% CI 0.97-0.99) and performance of a nerve sparing procedure were independent predictors. After adjusting for age, the hazard ratio was 1.61 (95% CI 1.25-2.07, p0.001) for partial nerve sparing and 1.44 (1.13-1.83, p = 0.003) for bilateral nerve sparing compared to the nonnerve sparing group. Median time (95% CI) to the recovery of continence was prolonged in the nonnerve sparing group compared to nerve sparing counterparts at 6 (5.12-6.88), 4 (3.60-4.40) and 5 weeks (4.70-5.30) in the nonnerve sparing, partial nerve sparing and bilateral nerve sparing groups, respectively, with log rank p0.01.Findings from our analysis indicate that the likelihood of postoperative urinary control was significantly higher in younger patients and when a nerve sparing procedure was performed.

Context: The purpose of this article is to review the history of robotic surgery, its impact on teaching as well as a description of historical and current robots used in the medical arena. Summary of evidence: Although the history of robots dates back to 2000 years or more, the last two decades have seen an outstanding revolution in medicine, due to all the changes that robotic surgery has made in the way of performing, teaching and practicing surgery. Conclusions: Robotic surgery has evolved into a complete and self-contained field, with enormous potential for future development. The results to date have shown that this technology is capable of providing good outcomes and quality care for patients. © 2011 AEU. Published by Elsevier Espana, S.L. All rights reserved.

• Historically, the ideal outcome of radical prostatectomy (RP) has been measured by achievement of the so-called 'trifecta', or the concurrent attainment of continence and potency with no evidence of biochemical recurrence. However, in the PSA era, younger and healthier men are more frequently diagnosed with prostate cancer. Such patients have higher expectations from the advanced minimally invasive surgical technologies. Mere trifecta is no longer an ideal outcome measure to meet the demands of such patients. • Keeping the limitations of trifecta in mind, we have earlier proposed a new method of outcomes analysis, called the 'pentafecta', which adds early complications and positive surgical margins (PSMs) to trifecta. • We performed a Medline search for articles reporting the complications, PSM rates, continence, potency and biochemical recurrence after robot-assisted RP. Related articles were selected and individual outcomes were reviewed.

Objectives To describe a technical modification during robotic-assisted simple prostatectomy (RASP) aiming to decrease perioperative blood loss, shorten the length of hospital stay and eliminate the need of postoperative continuous bladder irrigation. To describe perioperative outcomes, pathological findings and functional outcomes of our single-surgeon series using this technique. Methods We analysed six consecutive patients who underwent RASP using our technical modification between February and September 2010. Transrectal ultrasonography (TRUS) guided prostate biopsy was performed in all cases and revealed benign prostatic hyperplasia in two cases and benign prostatic hyperplasia plus chronic prostatitis in four cases. The mean estimated prostate volume in the TRUS was 157 ± 74 (range 90-300) mL and the average preoperative International Prostate Symptom score was 19.8 ± 9.6 (10-32). Two patients were in urinary retention before surgery. Our technique of RASP includes the standard operative steps reported during open and laparoscopic simple prostatectomy; however, with the addition of some technical modifications during the reconstructive part of the procedure. Following the resection of the adenoma, instead of performing the classical 'trigonization' of the bladder neck and closure of the prostatic capsule, we propose three modified surgical steps: plication of the posterior prostatic capsule, a modified van Velthoven continuous vesico-urethral anastomosis and, finally, suture of the anterior prostatic capsule to the anterior bladder wall. Results The patients' average age was 69 ± 4.9 (63-74) years; the mean estimated blood loss was 208 ± 66 (100-300) mL and the mean operative time was 90 ± 17.6 (75-120) min. All patients were discharged on postoperative day 1 without the need of continuous bladder irrigation at any time after RASP. No blood transfusion or perioperative complications were reported. The mean weight of the surgical specimen was 145 ± 41.6 (84-186) g. Histopathological evaluation revealed benign prostatic hyperplasia plus chronic prostatitis in five patients and prostatic adenocarcinoma (Gleason score 3+3, pT1a) with negative surgical margins in one patient. The mean serum prostate-specific antigen level decreased from 7 ± 2.5 (4.2-11) ng/mL preoperatively to 1.05 ± 0.8 (0.2-2.5) after RASP. Significant improvement from baseline was reported in the average International Prostate Symptom score (average preoperative vs postoperative, 19.8 ± 9.6 vs 5.5 ± 2.5, P= 0.01) and in mean maximum urine flow (average preoperative vs postoperative 7.75 ± 3.3 vs 19 ± 4.5 mL/s, P= 0.019) at 2 months after RASP. All patients were continent (defined as the use of no pads) at 2 months after RASP. Conclusions Our modified technique of RASP is a safe and feasible option for treatment of lower urinary tract symptoms caused by large prostatic adenomas. Potential advantages of our technique include reduced blood loss, lower blood transfusion rates and shorter length of hospital stay with no need of postoperative continuous bladder irrigation. Larger series with longer follow-up are necessary to determine long-term outcomes in comparison to open simple prostatectomy or to the standard technique of RASP.

Background Widespread use of prostate-specific antigen screening has resulted in younger and healthier men being diagnosed with prostate cancer. Their demands and expectations of surgical intervention are much higher and cannot be adequately addressed with the classic trifecta outcome measures. Objective A new and more comprehensive method for reporting outcomes after radical prostatectomy, the pentafecta , is proposed. Design, setting, and participants From January 2008 through September 2009, details of 1111 consecutive patients who underwent robot-assisted radical prostatectomy performed by a single surgeon were retrospectively analyzed. Of 626 potent men, 332 who underwent bilateral nerve sparing and who had 1 yr of follow-up were included in the study group. Measurements In addition to the traditional trifecta outcomes, two perioperative variables were included in the pentafecta: no postoperative complications and negative surgical margins. Patients who attained the trifecta and concurrently the two additional outcomes were considered as having achieved the pentafecta. A logistic regression model was created to evaluate independent factors for achieving the pentafecta. Results and limitations Continence, potency, biochemical recurrence–free survival, and trifecta rates at 12 mo were 96.4%, 89.8%, 96.4%, and 83.1%, respectively. With regard to the perioperative outcomes, 93.4% had no postoperative complication and 90.7% had negative surgical margins. The pentafecta rate at 12 mo was 70.8%. On multivariable analysis, patient age ( p =0.001) was confirmed as the only factor independently associated with the pentafecta. Conclusions A more comprehensive approach for reporting prostate surgery outcomes, the pentafecta , is being proposed. We believe that pentafecta outcomes more accurately represent patients' expectations after minimally invasive surgery for prostate cancer. This approach may be beneficial and may be used when counseling patients with clinically localized disease.

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE • To evaluate early trifecta outcomes after robotic-assisted radical prostatectomy (RARP) performed by a high-volume surgeon. PATIENTS AND METHODS • We evaluated prospectively 1100 consecutive patients who underwent RARP performed by one surgeon. In all, 541 men were considered potent before RARP; of these 404 underwent bilateral full nerve sparing and were included in this analysis. • Baseline and postoperative urinary and sexual functions were assessed using self-administered validated questionnaires. • Postoperative continence was defined as the use of no pads; potency was defined as the ability to achieve and maintain satisfactory erections for sexual intercourse >50% of times, with or without the use of oral phosphodiesterase type 5 inhibitors; Biochemical recurrence (BCR) was defined as two consecutive PSA levels of >0.2 ng/mL after RARP. • Results were compared between three age groups: Group 1, ≤55 years, Group 2, 56–65 years and Group 3, >65 years. RESULTS • The trifecta rates at 6 weeks, 3, 6, 12, and 18 months after RARP were 42.8%, 65.3%, 80.3%, 86% and 91%, respectively. • There were no statistically significant differences in the continence and BCR-free rates between the three age groups at all postoperative intervals analysed. • Nevertheless, younger men had higher potency rates and shorter time to recovery of sexual function when compared with older men at 6 weeks, 3, 6 and 12 months after RARP (P < 0.01 at all time points). • Similarly, younger men had higher trifecta rates at 6 weeks, 3 and 6 months after RARP compared with older men (P < 0.01 at all time points). CONCLUSION • RARP offers excellent short-term trifecta outcomes when performed by an experienced surgeon. • Younger men had higher overall trifecta rates when compared with older men at 6 weeks, 3 and 6 months after RARP.

Cancer prostate is the most commonly diagnosed cancer as well as the second most common cause of death in the United States of America. In 2009, as many 192,280 (25%) men were estimated as new diagnosis with prostate cancer (Jemal et al., CA Cancer J Clin 60(5):277–300, 2010). Of the several treatment options available, surgery is the gold standard and offers potential for long-term cure (Bil-Axelson et al., N Eng J Med 352(19):1977, 2005).

Background Although the retrograde approach to nerve sparing (NS) aimed at maximizing NS during robot-assisted radical prostatectomy (RARP) has been described, its significant benefits compared to the antegrade approach have not yet been investigated. Objective To evaluate the impact of NS approaches on perioperative, pathologic, and functional outcomes. Design, setting, and participants Five hundred one potent (Sexual Health Inventory for Men [SHIM] score >21) men underwent bilateral full NS and were followed up for a minimum of 1 yr. After propensity score matching, 344 patients were selected and were then categorized into two groups. Surgical procedure RARP with antegrade NS ( n =172) or RARP with retrograde NS ( n =172). Outcome measurements and statistical analysis Functional outcomes were assessed using validated questionnaires. Multivariable logistic regression models were applied. Results and limitations Positive margin rates were similar (11.1% vs 6.9%; p =0.192), and no correlation with the NS approach was found on regression analysis. At 3, 6, and 9 mo, the potency rate was significantly higher in the retrograde approach (65% vs 80.8% and 72.1% vs 90.1% and 85.3% vs 92.9%, respectively). The multivariable model indicated that the NS approach was an independent predictor for potency recovery at 3, 6, and 9 mo, along with age, gland size, and hyperlipidemia. After adjusting for these predictors, the hazard ratio (HR) for the retrograde relative to the antegrade approach was 2.462 (95% confidence interval [CI], 1.482–4.089; p =0.001) at 3, 4.024 (95% CI, 2.171–7.457; p p =0.044) at 9 mo. Regarding continence, the recovery rates at each time point and the mean time to regaining it were similar, and the method of NS had no effect on multivariable analysis. The absence of randomization is a major limitation of this study. Conclusions In patients with normal erectile function who underwent bilateral full NS, a retrograde NS approach facilitated early recovery of potency compared to that with an antegrade NS approach without compromising cancer control.

To determine whether the presence of median lobe (ML) affects perioperative outcomes, positive surgical margin (PSM) rates, and recovery of urinary continence after robot-assisted radical prostatectomy (RARP).We analyzed 1693 consecutive patients undergoing RARP performed by a single surgeon. Patients were analyzed in two groups based on the presence or not of a ML identified during RARP. Perioperative outcomes, PSM rates, and recovery of urinary continence were compared between the groups. Continence was assessed using validated questionnaires, and it was defined as the use of "no pads" postoperatively.A ML was identified in 323 (19%) patients. Both groups had similar estimated blood loss, length of hospital stay, pathologic stage, complication rates, anastomotic leakage rates, overall PSM rates, and PSM rate at the bladder neck. The median overall operative time was slightly greater in patients with ML (80 vs 75 min, P0.001); however, there was no difference in the operative time when stratifying this result by prostate weight. Continence rates were also similar between patients with and without ML at 1 week (27.8% vs 27%, P=0.870), 4 weeks (42.3% vs 48%, P=0.136), 12 weeks (82.5% vs 86.8%, P=0.107), and 24 weeks (91.5% vs 94.1%, P=0.183) after catheter removal. Finally, the median time to recovery of continence was similar between the groups (median: 5 wks, 95% confidence interval [CI]: 4.41-5.59 vs median: 5 wks, CI 4.66-5.34; log rank test, P=0.113).The presence of a ML does not affect outcomes of RARP performed by an experienced surgeon.

Yesterday’s humor is today’s reality. Robotic surgery provides the minimal invasiveness of laparoscopy with better precision, more freedom of motion, and lack of tremor. The initial step of training protocol for proficiency and credentialing in robot-assisted surgery would be skills on operating the robot in labs and then progressing onto mastery of procedure-specific nuances. Proctoring and preceptoring are two different but indispensible approaches to converting the laboratory and simulation expertise into operative ability. The training of the support team including the theater staff and first assistant is another important aspect of achieving proficiency and optimal outcomes in robotic urology. Ethical issues and cost factors limit the widespread use of robots in the training program.