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Background: The aim of this study was to evaluate the perioperative oncological and functional outcomes after robot-assisted radical prostatectomy (RALP) in older men.Patients and Methods: The records of n = 2,000 men who underwent RALP from February 2006 to April 2010 were retrospectively reviewed. A total of 45 patients ≥ 75 years were indentified. Subsequently this subgroup was compared to the overall patient cohort with regard to perioperative results, pathological tumor stage, functional outcomes after 12 months and the prostate cancer-specific mortality and biochemical recurrence free survival.Results: The following results reflect the comparison of the cohort of patients who were ≥75 years of age versus the overall cohort of patients. A statistical difference of the parameters analyzed was observed only for minor complications 15.5 % versus 11.4 % (p<0.05), neurovascular bundle (NVB) preservation 51.1 % versus 65.7 % (p<0.05) and potency after 12 months 39.6 % versus 66.2 % (p<0.001). Major complications were noted in 2.2 % versus 1.3 % of cases. A Gleason score <7 was noted in 37.4 % versus 42.8 %, a Gleason score 7 in 51.1 % versus 47.7 % and a Gleason score >7 in 11.6 % versus 9.5 %. Tumor stages pT2 and pT3 were noted in 68.8 % versus 73.5 % and in 31.2 % versus 25.2 %, respectively. The positive surgical margin status was encountered in 11.1 % versus 8.9 % of cases, respectively. At 12 months 86.9 % versus 92.8 % of patients were continent and 39.6 % versus 66.2 % were potent, respectively. After a median follow-up of 17.2 months the prostate cancer-specific mortality in the subgroup of elderly patients was 0 % and the biochemical recurrence-free survival was 95.5%.Conclusions: The RALP approach in patients ≥75 years of age is a safe surgical procedure with a limited complication rate, excellent oncologic and continence outcomes as well as acceptable erectile function. Nevertheless, RALP should be limited to a selected cohort of patients with a good health status and an individual life expectancy of more than 10 years. For the assessment of the final oncological benefits of RALP in this patient population a longer follow-up is necessary. [ABSTRACT FROM AUTHOR]

Background: As a local treatment for prostate cancer (PCa), robot-assisted radical prostatectomy (RARP) may have a quality of life (QoL) benefit over open surgery. Recent analyses revealed substantial between-country differences in the function and symptom scale scores for the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), which is typically used to assess patient-reported QoL. Such differences could have implications for multinational studies in PCa., Objective: To examine whether nationality is significantly associated with patient-reported QoL., Design, Setting, and Participants: The study cohort comprised Dutch and German patients with PCa treated with RARP in a single high-volume prostate center from 2006 to 2018. Analyses were restricted to patients who were preoperatively continent with at least one follow-up time point., Outcome Measurements and Statistical Analysis: QoL was measured in terms of the global Quality of Life (QL) scale score and the overall summary score for the EORTC QLQ-C30. Linear mixed models for repeated-measures multivariable analyses (MVAs) were used to examine the association between nationality and both the global QL score and the summary score. MVAs were further adjusted for QLQ-C30 baseline values, age, Charlson comorbidity index, preoperative prostate-specific antigen, surgical expertise, pathological tumor and nodal stage, Gleason grade, degree of nerve-sparing, surgical margin status, 30-d Clavien-Dindo grade complications, urinary continence recovery, and biochemical recurrence/postoperative radiotherapy., Results and Limitations: For Dutch (n = 1938) versus German (n = 6410) men, the mean baseline scores were 82.8 versus 71.9 for the global QL scale score and 93.4 versus 89.7 for the QLQ-C30 summary score. Urinary continence recovery (QL: +8.9, 95% confidence interval [CI] 8.1-9.8; p < 0001) and Dutch nationality (QL: +6.9, 95% CI 6.1-7.6; p < 0001) were the strongest positive contributors to the global QL and summary scores, respectively. The main limitation is the retrospective study design. In addition, our Dutch cohort may not be representative of the general Dutch population and reporting bias cannot be ruled out., Conclusions: Our findings provide observational evidence under specific conditions involving the same setting for patients of two different nationalities suggesting that cross-national patient-reported QoL differences appear to be real and may need to be taken into consideration in multinational studies., Patient Summary: We observed differences in the quality-of-life scores reported by Dutch and German patients with prostate cancer after they underwent robot-assisted removal of the prostate. These findings should be taken into consideration in cross-national studies., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: Aquablation and holmium laser enucleation of the prostate (HoLEP) have evolved as established therapeutic options for men with benign prostatic obstruction (BPO). We sought to compare the rates of incidental prostate cancer (iPCa) after aquablation and HoLEP., Methods: At our center, between January 2020 and November 2022, 317 men underwent aquablation, and 979 men underwent HoLEP for BPO. Histopathological assessment of resected tissue was conducted in all cases. If iPCa was detected, the Gleason score and percentage of affected tissue were assessed. Differences in important predictive factors for prostate cancer between study groups were accounted for by additional matched pairs analysis (with matching on age ± 1 year; PSA ± 0.5 ng/mL; and prostate volume ± 5 mL)., Results: Histopathology revealed iPCas in 60 patients (4.6%): 59 (6.03%) after HoLEP and 1 (0.3%) after aquablation (p = 0.001). Of 60 of incidental cancers, 11 had a Gleason score ≥7 (aquablation: 1/1 [100%]; HoLEP: 10/59 [16.9%]). The aquablation and HoLEP study groups differed in patient age, preoperative PSA, and prostate volume. Therefore, matched pairs analysis (aquablation: 132 patients; HoLEP: 132 patients) was conducted to improve comparability. Also after the matching procedure, significantly fewer iPCas were diagnosed after aquablation than HoLEP (aquablation: 0 [0%]; HoLEP: 6 [4.5%]; p = 0.015)., Conclusion: Significantly fewer iPCas were identified after aquablation than HoLEP procedures. Histopathologic assessment of tissue after aquablation is feasible and may lead to the diagnosis of clinically significant iPCa. Therefore, histopathologic examination of the aquablation resective tissue should not be omitted., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Background: Little is known regarding functional outcomes after robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction., Objective: To report on urinary continence (UC) and erectile function (EF) at 12 mo after RARC and ICNB reconstruction and investigate predictors of these outcomes., Design, Setting, and Participants: We used data from a multi-institutional database of patients who underwent RARC and ICNB reconstruction for bladder cancer., Surgical Procedure: The cystoprostatectomy sensu stricto followed the conventional steps. ICNB reconstruction was performed at the physician's discretion according to the Studer/Wiklund, S pouch, Gaston, vescica ileale Padovana, or Hautmann technique. The techniques are detailed in the video accompanying the article., Measurements: The outcomes measured were UC and EF at 12 mo., Results and Limitations: A total of 732 male patients were identified with a median age at diagnosis of 64 yr (interquartile range 58-70). The ICNB reconstruction technique was Studer/Wiklund in 74%, S pouch in 1.5%, Gaston in 19%, vescica ileale Padovana in 1.5%, and Hautmann in 4% of cases. The 12-mo UC rate was 86% for daytime and 66% for nighttime continence, including patients who reported the use of a safety pad (20% and 32%, respectively). The 12-mo EF rate was 55%, including men who reported potency with the aid of phosphodiesterase type 5 inhibitors (24%). After adjusting for potential confounders, neobladder type was not associated with UC. Unilateral nerve-sparing (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.88-7.85; p < 0.001) and bilateral nerve-sparing (OR 6.25, 95% CI 3.55-11.0; p < 0.001), were positively associated with EF, whereas age (OR 0.93, 95% CI 0.91-0.95; p < 0.001) and an American Society of Anesthesiologists score of 3 (OR 0.46, 95% CI 0.25-0.89; p < 0.02) were inversely associated with EF., Conclusions: RARC and ICNB reconstruction are generally associated with good functional outcomes in terms of UC. EF is highly affected by the degree of nerve preservation, age, and comorbidities., Patient Summary: We investigated functional outcomes after robot-assisted removal of the bladder in terms of urinary continence and erectile function. We found that, in general, patients have relatively good functional outcomes at 12 months after surgery., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: To assess if systematic (SBx) vs. transrectal or transperineal mpMRI-ultrasound targeted combined with systematic (TBx + SBx) biopsy confer different effects on treatment delay to radical prostatectomy measured as Gleason grade group (GGG) upgrade of prostate cancer (PCa)., Materials and Methods: We relied on a multi-institutional cohort of localized PCa patients who underwent RP in Martini-Klinik, Hamburg, or Prostate Center Northwest, Gronau, between 2014 and 2022. Analyses were restricted to PCa GGG 1-3 diagnosed at SBx (n = 4475) or TBx + SBx (n = 1282). Multivariable logistic regression modeling (MVA) predicting RP GGG upgrade of ≥ 1 was performed separately for SBx and TBx + SBx., Results: Treatment delay to RP of < 90, 90-180 and 180-365 days was reported in 59%, 35% and 6.2% of SBx and in 60%, 34% and 5.9% of the TBx + SBx patients, respectively. Upgrade to GGG ≥ 4 at RP was detected in 15% of SBx patients and 0.86% of TBx patients. In MVA performed for SBx, treatment delay yielded independent predictor status (OR 1.17 95% CI 1.02-1.39, p = 0.028), whereas for TBx + SBx MVA, statistical significance was not achieved., Conclusion: Treatment delay remained independently associated with radical prostatectomy GGG upgrade after adjustment for clinical variables in the patients diagnosed with SBx alone, but not in those who received combined TBx + SBx. These findings can be explained through inherent misclassification rates of SBx, potentially obfuscating historical observations of natural PCa progression and potential dangers of treatment delay. Thus, mpMRI-guided combined TBx + SBx appears mandatory for prospective delay-based examinations of PCa., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: The aim of this study was to evaluate the prognostic impact of concomitant prostate cancer (PCa) of the cancer-specific mortality (CSM) in the aging patient's papulation with bladder cancer (BCa) treated with radical cystoprostatectomy (RCP)., Materials and Methods: Within the SEER database (2004-2015), 1468 patients were treated with RCP for BCa harboring histopathological PCa findings. To account for other cause mortality (OCM), multivariable competing risk regression (CRR) tested for potential BCa-CSM differences according to PCa characteristics risk factors predicting CSM., Results: CRR analysis revealed that only following BCa characteristics, as high pathological tumor stages(Ta/Tis/T1 [REF.] vs. T2; HR 2.03, 95% CI: 1.16-3.57, p  = 0.014 vs. T3; HR 4.32, 95% CI: 2.45-7.61, p  < 0.001 vs. T4; HR 5.06, 95% CI: 2.77-9.22, p  < 0.001), as well unfavorable BCa grade IV (Grade I-II [REF.] vs. Grade IV; HR 0.58, 95% CI: 0.35-0.98, p  < 0.041) achieved independent predictor status of CSM. With regard to PCa characteristics, none of the covariates yielded independent predictor status of CSM., Conclusions: Our study, based on the largest population cohort, demonstrates that even in organ-confined BCa patients, concomitant PCa as second malignancy does not represent a risk factor for survival.

Purpose: We assessed the diagnostic yield of consecutive transperineal targeted biopsy of multiparametric magnetic resonance imaging index lesion and secondary lesion and additive systematic biopsy in patients who received combined targeted biopsy+systematic biopsy of prostate., Materials and Methods: Of 1,467 patients with targeted biopsy+systematic biopsy, analyses were restricted to 571 patients with index lesion+secondary lesion, Prostate Imaging-Reporting and Data System score ≥3. Index lesion was defined as having the greatest Prostate Imaging-Reporting and Data System score and/or lesion volume as opposed to secondary lesion. We retrospectively compared clinically significant prostate cancer rates (ie, Gleason Grade Group ≥2) between index lesion+secondary lesion and index lesion+secondary lesion+systematic biopsy. Subgroup analyses in men with ipsilateral index lesion+secondary lesion focused on contralateral systematic biopsy. Multivariable logistic regression analyses to predict any clinically significant prostate cancer included age, previous biopsies, prostate specific antigen density, respective index lesion/secondary lesion volumes, side relation, Prostate Imaging-Reporting and Data System strata, and number of targeted biopsy and systematic biopsy cores., Results: Clinically significant prostate cancer rates for index lesion+secondary lesion vs index lesion+secondary lesion+systematic biopsy were 38% vs 42% ( P = .2) at expense of significantly higher median number of biopsy cores (9 vs 25, P < .001). In the subgroup with ipsilateral index lesion+secondary lesion (n = 236), contralateral systematic biopsy detected clinically significant prostate cancer in 17%. In the narrower subgroup with ipsilateral index lesion+secondary lesion (n = 131) without any clinically significant prostate cancer, contralateral systematic biopsy detected clinically significant prostate cancer in 3.8%. Multivariable logistic regression analyses confirmed contralateral systematic biopsy as independent predictor, but performed similarly without systematic biopsy information (area under the curve 87.1% vs 86.6%)., Conclusions: Targeted biopsy of secondary lesion should be included in targeted biopsy protocols due to added diagnostic information. However, for targeted biopsy of index lesion+secondary lesion additional systematic biopsy is of limited informative value in terms of overall clinically significant prostate cancer detection. However, when index lesion+secondary lesion are ipsilateral, contralateral systematic biopsy should be recommended for purpose of prostate lobe information. Our results indicate great potential to reduce systematic biopsy cores and associated potential morbidity, and warrant prospective evaluation.

Objectives: The aim of this study was to assess whether age ≥75 years impairs surgical, functional, and oncological outcomes after robot-assisted radical prostatectomy (RARP)., Materials and Methods: Patients with prostate cancer (PCa) were stratified in ≥75( n  = 669) vs. <70 years( n  = 8,268). Multivariable cox regression analyses (MVA) tested for effect of senior age on erectile function-, urinary continence-recovery, biochemical recurrence (BCR), and metastatic progression (MP)., Results: RARP duration, blood loss, and 30d complication rates were similar between groups. For patients ≥75 vs. <70 years, rates of erectile function after 36 and urinary continence after 12 months were 27 vs. 56% ( p  < 0.001) and 85 vs. 86% ( p  = 0.99), respectively. Mean quality of life (QoL) score after 12 months improved in both groups ( p  = 0.9). At 48 months, BCR- and MP-free rates were 77 vs. 85% ( p  < 0.001) and 97 vs. 98% ( p  = 0.3), respectively. MVA confirmed the negative effect of senior age on erectile function but no significant effect on urinary continence, BCR or MP, before and after propensity score matching., Conclusion: Apart from erectile function, senior age has no significant effect on urinary continence recovery, BCR- or MP-free rates after RARP. Post-RARP QoL improved even in senior patients. Modern therapy of senior PCa patients should be based on individual counseling than just age.

Background: Since the introduction of minimally invasive surgery, the number of simulation models available for teaching new surgeons has continued to increase., Objective: To evaluate and validate use of a model for teaching robot-assisted pyeloplasty., Design Setting and Participants: Twenty simulated robot-assisted pyeloplasty procedures were performed by experienced ( n  = 4) and novice ( n  = 16) surgeons using a chicken crop model at two different training centers using third- and fourth-generation robotic systems., Outcome Measurements and Statistical Analysis: We evaluated the time needed to perform the procedure, and the sufficiency and patency of the anastomosis. Participants rated the efficiency, face validity, and possible acceptance of the model as part of a structured curriculum on a scale from 0 to10. Statistical significance for comparison of results was set at p  < 0.05., Results and Limitations: Robot-assisted pyeloplasty was successfully performed by 75% of the participants. The completion time was significantly higher in the novice group ( p  = 0.016). The model was deemed to be similar to the human ureteropelvic junction by the novice group. Both groups regarded the model as a useful simulation task as part of a standardized training curriculum, with mean scores of 6.5 versus 8.69 ( p  = 0.046) for face validity and 8 versus 9.25 for acceptance ( p  = 0.053) reported by the experienced versus novice group, respectively. Limitations of the study are the costs associated with the robotic system and the unequal number of participants in the groups., Conclusions: The chicken crop model is a low-cost and reproducible simulation model for accomplishing both the resection and reconstructive steps during the learning phase for robot-assisted pyeloplasty., Patient Summary: We assessed the use of chickens as a model for practicing a robot-assisted operation called pyeloplasty to fix narrowing of the ureter (the tube that drains urine from the kidney to the bladder) where it attaches to the kidney. This model can be used for simulation of robot-assisted pyeloplasty when training new robotic surgeons., (© 2022 The Authors.)

Background: Robot-assisted partial nephrectomy (RAPN) is a challenging procedure that is influenced by a multitude of factors., Objective: To assess the impact of prior surgical experience on perioperative outcomes in RAPN., Design Setting and Participants: In this retrospective multicenter study, results for 2548 RAPNs performed by 25 surgeons at eight robotic referral centers were analyzed. Perioperative data for all consecutive RAPNs from the start of each individual surgeon's experience were collected, as well as the number of prior open or laparoscopic kidney surgeries, pelvic surgeries (open, laparoscopic, robotic), and other robotic interventions., Intervention: Transperitoneal or retroperitoneal RAPN., Outcome Measurements and Statistical Analysis: The impact of prior surgical experience on operative time, warm ischemia time (WIT), major complications, and margin, ischemia, complication (MIC) score (negative surgical margins, WIT ≤20 min, no major complications) was assessed via univariate and multivariable regression analyses accounting for age, gender, body mass index (BMI), American Society of Anesthesiologists score, PADUA score, and RAPN experience., Results and Limitations: BMI, PADUA score, and surgical experience in RAPN had a strong impact on perioperative outcomes. A plateau effect for the learning curve was not observed. Prior laparoscopic kidney surgery significantly reduced the operative time ( p  < 0.001) and WIT ( p  < 0.001) and improved the MIC rate ( p  = 0.022). A greater number of prior robotic pelvic interventions decreased WIT ( p  = 0.011) and the rate of major complications ( p  < 0.001) and increased the MIC rate ( p  = 0.011), while prior experience in open kidney surgery did not. One limitation is the short-term follow-up., Conclusions: Mastering of RAPN is an ongoing learning process. However, prior experience in laparoscopic kidney and robot-assisted pelvic surgery seems to improve perioperative outcomes for surgeons when starting with RAPN, while experience in open surgery might not be crucial., Patient Summary: In this multicenter analysis, we found that a high degree of experience in keyhole kidney surgery and robot-assisted pelvic surgery helps surgeons in achieving good initial outcomes when starting robot-assisted kidney surgery., (© 2022 The Author(s).)

Objective: To assess the potential for molecular staging in biopsies of the prostatic fossa after radical prostatectomy (RP) by searching for occult tumour cells through analysis of glutathione S-transferase P1 (GSTP1) methylation status., Patients and Methods: We analysed 2446 biopsies: 2286 biopsies from a group of 254 patients with clinically organ-confined prostate cancer who underwent RP and 160 biopsies from a control group of 32 patients. After prostate gland excision, biopsies were obtained from defined areas of the prostatic fossa and bisected for histopathological and molecular genetics analyses. Results were related to clinicopathological data including tumour stage, lymph node status, resection status, tumour grading, initial PSA level, and biochemical recurrence., Results: In total, 34 patients (13.4%) had at least one core positive for the GSTP1 promoter hypermethylation, six of whom (17.6%) were characterised as having a clinically localised tumour stage (pT2, pN0) and 28 (82.4%) as an advanced tumour stage (≥pT3 and/or pN1). GSTP1 promoter hypermethylation significantly correlated with tumour stage (P < 0.001), International Society of Urological Pathology grading (P = 0.001), lymph node status (P < 0.001), surgical margin status (P < 0.001), and biochemical recurrence (P = 0.001). Furthermore, in 46 patients (18.1%) further analysis led to a down- or upgrading of conventional surgical margin status. Classical R-status (margins of the specimen) is significantly superior to histological sampling from the fossa (P = 0.006) but not to GSTP1 analysis from the fossa (P = 0.227)., Conclusion: For the detection of residual tumour in the fossa after RP in order to better predict recurrence, molecular GSTP1 promoter hypermethylation has some value; however, the classical R-status (margins of the specimen) is simpler and more widely applicable with similar results., (© 2021 The Authors. BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Background: The aim of this study was to assess insignificant prostate cancer (iPCa) rates after robot-assisted radical prostatectomy (RARP) in contemporary patients who were preoperatively eligible for active surveillance (AS). iPCa indicates no risk of PCa progression., Methods: We retrospectively analyzed 2837 RARP patients (2010-2019) who fulfilled at least one AS entry criteria set: Prostate Cancer Research International - Active Surveillance (PRIAS), University of California San Francisco (UCSF) (San Francisco, CA, USA), National Comprehensive Cancer Network (NCCN) or University of Toronto, ON, Canada. We utilized four different iPCa definitions: 1) based on pT2 and Gleason Score ≤6 and also cumulative tumor-volume; 2) ≤2.5mL; 3) ≤0.7mL; or 4) ≤0.5mL. For each AS set we tested the rates of iPCa and compared between age <70 vs. ≥70 years. This was complemented by multivariable logistic regression (LRM) predicting iPCa, adjusted for age and clinical AS variables. Finally, within the subgroup who had iPCa, we tested the rate of those who were deemed preoperatively AS ineligible., Results: Between most (PRIAS) and least stringent (TORONTO) AS sets, iPCa was correctly predicted in 70-57%. Similarly, for iPCa definitions 2-4, rates were 59-42%, 34-19% and 27-14%. Senior patients harbored decreased proportions of iPCa. LRM confirmed that advanced age is associated with a lower chance of iPCa. More stringent AS sets lead to higher rates of AS ineligibility, e.g. 53% for PRIAS, despite iPCa., Conclusions: AS sets show limited accuracy for stricter iPCa definitions, which further declined with advanced age. Greater AS stringency resulted in more AS ineligible patients despite harboring iPCa. In consequence, patients are at risk for overtreatment. Clinicians must consider age and different AS sets that result in highly variable detection rates of iPCa.

Purpose: The purpose of this study was to investigate the effect of a surgically constructed bilateral peritoneal flap (PIF) as an adjunct to robot-assisted radical prostatectomy (RARP) and pelvic lymph node dissection (PLND) on the incidence of lymphoceles., Materials and Methods: A total of 530 men with localized prostate cancer underwent a RARP with bilateral extended standardized PLND in a prospective randomized controlled trial. In group A, a PIF was created by suturing the margins of the bladder peritoneum to the ipsilateral endopelvic fascia at 2 points on each side. In group B, no PIF was created. The patients were followed 30 and 90 days after the surgery to assess the incidence, extent and treatment of lymphoceles., Results: Lymphoceles occurred in 22% of group A patients and 33% of group B patients (p=0.008). Symptomatic lymphoceles were observed in 3.3% of group A patients and 8.1% of group B patients (p=0.027). Lymphoceles requiring intervention occurred significantly less frequently in group A patients (1.3%) than in group B patients (6.8%, p=0.002). The median lymphocele size was 4.3 cm in group A and 5.0 cm in group B (p=0.055). No statistically significant differences were observed in minor or major complications unrelated to lymphocele, blood loss, or surgical time between groups A and B., Conclusions: Bilateral PIFs in conjunction with RARP and PLND significantly reduce the total incidence of lymphoceles, the frequency of symptomatic lymphoceles and the rate of associated secondary interventions.

Objective: To assess suitability of Comprehensive Complication Index (CCI ® ) vs. Clavien-Dindo classification (CDC) to capture 30-day morbidity after robot-assisted radical cystectomy (RARC)., Materials and Methods: A total of 128 patients with bladder cancer (BCa) undergoing intracorporeal RARC with pelvic lymph node dissection between 2015 and 2021 were included in a retrospective bi-institutional study, which adhered to standardized reporting criteria. Thirty-day complications were captured according to a procedure-specific catalog. Each complication was graded by the CDC and the CCI ® . Multivariable linear regression (MVA) was used to identify predictors of higher morbidity., Results: 381 complications were identified in 118 patients (92%). 55 (43%), 43 (34%), and 20 (16%) suffered from CDC grade I-II, IIIa, and ≥ IIIb complications, respectively. 16 (13%), 27 (21%), and 2 patients (1.6%) were reoperated, readmitted, and died within 30 days, respectively. 31 patients (24%) were upgraded to most severe complication (CCI ®  ≥ 33.7) when calculating morbidity burden compared to corresponding CDC grade accounting only for the highest complication. In MVA, only age was a positive estimate (0.44; 95% CI = 0.03-0.86; p = 0.04) for increased cumulative morbidity., Conclusion: The CCI ® estimates of 30-day morbidity after RARC were substantially higher compared to CDC alone. These measurements are a prerequisite to tailor patient counseling regarding surgical approach, urinary diversion, and comparability of results between institutions., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Since the beginning of the pandemic in 2020, COVID-19 has changed the medical landscape. International recommendations for localized prostate cancer (PCa) include deferred treatment and adjusted therapeutic routines., Materials and Methods: To longitudinally evaluate changes in PCa treatment strategies in urological and radiotherapy departments in Germany, a link to a survey was sent to 134 institutions covering two representative baseline weeks prior to the pandemic and 13 weeks from March 2020 to February 2021. The questionnaire captured the numbers of radical prostatectomies, prostate biopsies and case numbers for conventional and hypofractionation radiotherapy. The results were evaluated using descriptive analyses., Results: A total of 35% of the questionnaires were completed. PCa therapy increased by 6% in 2020 compared to 2019. At baseline, a total of 69 radiotherapy series and 164 radical prostatectomies (RPs) were documented. The decrease to 60% during the first wave of COVID-19 particularly affected low-risk PCa. The recovery throughout the summer months was followed by a renewed reduction to 58% at the end of 2020. After a gradual decline to 61% until July 2020, the number of prostate biopsies remained stable (89% to 98%) during the second wave. The use of RP fluctuated after an initial decrease without apparent prioritization of risk groups. Conventional fractionation was used in 66% of patients, followed by moderate hypofractionation (30%) and ultrahypofractionation (4%). One limitation was a potential selection bias of the selected weeks and the low response rate., Conclusion: While the diagnosis and therapy of PCa were affected in both waves of the pandemic, the interim increase between the peaks led to a higher total number of patients in 2020 than in 2019. Recommendations regarding prioritization and fractionation routines were implemented heterogeneously, leaving unexplored potential for future pandemic challenges., Competing Interests: The authors have declared that no competing interests exist.

Objective: To compare surgical, oncological and functional outcomes between obese vs. normal-weight prostate cancer (PCa) patients treated with robotic-assisted radical prostatectomy (RARP)., Materials and Methods: We assessed 4555 consecutive RARP patients from a high-volume center 2008-2018. Analyses were restricted to normal-weight vs. obese patients (≥ 30 kg/m 2 ). Multivariable cox regression analyses (MVA) assessed the effect of obesity on biochemical recurrence (BCR), metastatic progression (MP), erectile function and urinary continence recovery. Analyses were repeated after propensity score matching., Results: Before matching, higher rates of pathological Gleason Grade group ≥ 4 (14 vs. 18%; p = 0.004) and pT3 stage (33 vs. 35%; p = 0.016) were observed in obese patients, with similar observations for surgery time, blood loss and 30-day wound- and surgical complication rates. For normal-weight vs. obese patients, BCR- and MP-free rates were 86 vs. 85% (p = 0.97) and 97.5 vs.97.8% (p = 0.8) at 48 months. Similarly, rates of erectile function at 36 months and urinary continence at 12 months were 56 vs. 49% (p = 0.012) and 88 vs. 85% (p = 0.003), respectively. Before and after propensity score matching, obesity had no effect on BCR or MP, but a negative effect on erectile function (matched HR 0.87, 95%CI 0.76-0.99; p = 0.029) and urinary continence recovery (matched HR 0.91, 95%CI 0.84-0.98; p = 0.014)., Conclusions: Obesity did not represent a risk factor of BCR or MP after RARP despite higher rates of adverse pathological features. However, obesity was associated with higher risk of perioperative morbidity and impaired functional outcomes. Such information is integral for patient counselling. Thus, weight loss before RARP should be encouraged., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: There is a recent paradigm shift to extend robot-assisted radical prostatectomy (RARP) to very senior prostate cancer (PCa) patients based on biological fitness, comorbidities, and clinical PCa assessment that approximates the true risk of progression. Thus, we aimed to assess misclassification rates between clinical vs. pathological PCa burden., Materials and Methods: We compared senior patients with PCa ≥75 y ( n = 847), who were propensity score matched with younger patients <75 y ( n = 3,388) in a 1:4 ratio. Matching was based on the number of biopsy cores, prostate volume, and preoperative Cancer of the Prostate Risk Assessment (CAPRA) risk groups score. Multivariable logistic regression models (LRMs) predicted surgical CAPRA (CAPRA-S) upgrade, which was defined as a higher risk of the CAPRA-S in the presence of lower-risk preoperative CAPRA score. LRM incorporated the same variables as propensity score matching. Moreover, patients were categorized as low-, intermediate-, and high-risk, preoperative and according to their CAPRA and CAPRA-S scores., Results: Surgical CAPRA risk strata significantly differed between the groups. Greater proportions of unfavorable intermediate risk (39 vs. 32%) or high risk (30 vs. 28%; p < 0.001) were observed. These proportions are driven by greater proportions of International Society of Urological Pathology (ISUP) Gleason Grade Group 4 or 5 (33 vs. 26%; p = 0.001) and pathological tumor stage (≥T3a 54 vs. 45%; p < 0.001). Increasing age was identified as an independent predictor of CAPRA-S-based upgrade (age odds ratio [OR] 1.028 95% CI 1.02-1.037; p < 0.001)., Conclusion: Approximately every second senior patient has a misclassification in (i.e., any up or downgrade) and each 4.5th senior patient specifically has an upgrade in his final pathology that directly translates to an unfavorable PCa prognosis. It is imperative to take such substantial misclassification rates into account for this sensitive PCa demographic of senior men. Future prospective studies are warranted to further optimize PCa workflow and diagnostics, such as to incorporate modern imaging, molecular profiling and implement these into biopsy strategies to identify true PCa burden., Competing Interests: JW is a paid proctor and consultant for Intuitive Surgical and Board member of the German Society of Robot-Assisted Urology. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Liakos, Witt, Rachubinski and Leyh-Bannurah.)

The quality of life (QoL) of men with optimal outcomes after robot-assisted radical prostatectomy (RARP) is largely unexplored. Thus we assessed meaningful changes of QoL measured with the EORTC QLQ-C30 24 months after RARP according to postsurgical Cancer of the Prostate Risk Assessment score (CAPRA-S) and pentafecta criteria. 2871 prostate cancer (PCa) patients with completed EORTC QLQ-C30 were stratified according to CAPRA-S, pentafecta (erectile function recovery, urinary continence recovery, biochemical-recurrence-free survival (BFS), negative surgical margins) and 90-day Clavien-Dindo-complications (CDC) ≤ 3a. Multivariable logistic regression analyses (LRM) aimed to predict improvement of EORTC QoL. Mean preoperative QoL values did not significantly differ between CAPRA-S low- (LR) vs. high-risk (HR, 75.7 vs. 75.2; p = 0.7) and pentafecta vs. non-pentafecta groups (75.6 vs. 75.2; p = 0.6). After RARP, stable QoL rates for CAPRA-S LR vs. HR and pentafecta were 30, 26 and 30%, respectively. Corresponding improved QoL rates were 44, 32 and 47%. In LRM, CAPRA-S and pentafecta criteria were independent predictors of improved QoL. We conclude that most favourable combined outcomes after RARP might confer stable or even improved QoL but up to one third of patients might experience deterioration. This warrants further investigation how to capture the underlying cause and to address and potentially solve these perceived negative effects despite successful RARP., (© 2022. The Author(s).)

The aim of this study was to assess clinically meaningful differences of preoperative lower urinary tract symptoms (LUTS) and quality of life (QoL) before and after robot-assisted radical prostatectomy (RARP). Therefore we identified 5506 RARP patients from 2007 to 2018 with completed International Prostate Symptom Score (IPSS) and -QoL questionnaires before and 12 months after RARP in our institution. Marked clinically important difference (MCID) was defined by using the strictest IPSS-difference of - 8 points. Multivariable logistic regression analyses (LRM) aimed to predict ∆IPSS ≤ - 8 and were restricted to RARP patients with preoperatively moderate (IPSS 8-19) vs. severe (IPSS 20-35) LUTS burden (n = 2305). Preoperative LUTS was categorized as moderate and severe in 37% (n = 2014) and 5.3% of the complete cohort (n = 291), respectively. Here, a postoperative ∆IPSS ≤ - 8, was reported in 38% vs. 90%. In LRM, younger age (OR 0.98, 95%CI 0.97-0.99; p = 0.007), lower BMI (OR 0.94, 95%CI 0.92-0.97; p < 0.001), higher preoperative LUTS burden (severe vs. moderate [REF.] OR 15.6, 95%CI 10.4-23.4; p < 0.001), greater prostate specimen weight (per 10 g, OR 1.12, 95%CI 1.07-1.16; p < 0.001) and the event of urinary continence recovery (OR 1.66 95%CI 1.25-2.21; p < 0.001) were independent predictors of a marked LUTS improvement after RARP. Less rigorous IPSS-difference of - 5 points yielded identical predictors. To sum up, in substantial proportions of patients with preoperative moderate or severe LUTS a marked improvement of LUTS and QoL can be expected at 12 months after RARP. LRM revealed greatest benefit in those patients with preoperatively greatest LUTS burden, prostate enlargement, lower BMI, younger age and the event of urinary continence recovery., (© 2021. The Author(s).)

Purpose: Prostate cancer patients who are scheduled for robot-assisted radical prostatectomy often have a history of transurethral resection or laser enucleation of the prostate as treatment of benign prostatic hyperplasia. We examined if these patients have impaired surgical, functional and oncologic outcomes compared to those who have no symptom burden of moderate to severe benign prostatic hyperplasia and no previous transurethral resection or laser enucleation of the prostate., Materials and Methods: We compared 368 robot-assisted radical prostatectomy patients with previous transurethral resection or laser enucleation of the prostate (group A) to 4,945 robot-assisted radical prostatectomy patients without transurethral resection or laser enucleation of the prostate and without moderate or severe benign prostatic hyperplasia symptoms (group B) at a high-volume robot-assisted radical prostatectomy center. Multivariable Cox regression analyses assessed impact of transurethral resection or laser enucleation of the prostate on erectile function and urinary continence recovery, biochemical recurrence or metastatic progression. Analyses were repeated after propensity score matching., Results: No relevant differences in surgical outcomes, such as surgical margin and 30-day complications rates, were observed. Urinary continence recovery rates at 12 months were 67% vs 74% (group A vs B; p <0.001). Erectile function recovery rates at 24 months were 52% vs 62% (p <0.001). Biochemical recurrence-free rates at 36 months were identical, at 87.3% vs 87.8%. Before and after propensity score matching, transurethral resection or laser enucleation of the prostate negatively affected erectile function recovery (matched HR 0.68, 95% CI 0.53-0.88; p=0.003) in multivariable Cox regression analyses. Similarly, transurethral resection or laser enucleation of the prostate had negative effect on urinary continence recovery (HR 0.84, 95% CI 0.73-0.97; p=0.015) but no effect on biochemical recurrence or metastatic progression., Conclusions: Previous transurethral resection or laser enucleation of the prostate does not negatively impact surgical, complication-related, and oncologic outcomes if the robot-assisted radical prostatectomy is performed by highly experienced surgeons. However, transurethral resection or laser enucleation of the prostate negatively affects erectile function and urinary continence recovery.

Purpose: Robotic-assisted simple prostatectomy (RASP) has recently been studied as an alternative to open simple prostatectomy or endoscopic treatment options. At present, there is no defined recommendation for a robotic procedure as a standard surgical technique to treat large benign prostate hyperplasia., Methods: Several robotic techniques have been described since 2007. Contemporaneously, multiple endoscopic enucleation techniques have been proposed. Nevertheless, open simple prostatectomy still remains a mainstay of therapy. We aimed to evaluate the development of robotic-assisted prostatectomy for large benign prostatic obstruction, thus comparing the technical aspects and clinical outcomes with open and endoscopic enucleation., Results: Robotic-assisted simple prostatectomy provides significantly less blood loss and shorter hospital stay but longer operative time compared to open simple prostatectomy. Compared to endoscopic treatments, robotic approaches have a similar perioperative outcome, but cause less urethral trauma or potential bladder neck strictures. Moreover, concomitant bladder pathologies can be treated within the same setting., Conclusion: Robotic-assisted simple prostatectomy is an effective and safe technique, and can hence be considered to become the preferred first-line therapy to treat patients with obstructive large prostate glands., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: To externally validate the currently available nomograms for predicting lymph node invasion (LNI) in patients with prostate cancer (PCa) and to assess the potential risk of complications of extended pelvic lymph node dissection (ePLND) when using the recommended threshold., Methods: A total of 14 921 patients, who underwent radical prostatectomy with ePLND at eight European tertiary referral centres, were retrospectively identified. After exclusion of patients with incomplete biopsy or pathological data, 12 009 were included. Of these, 609 had undergone multiparametic magnetic resonance imaging-targeted biopsies. Among ePLND-related complications we included lymphocele, lymphoedema, haemorrhage, infection and sepsis. The performances of the Memorial Sloan Kettering Cancer Centre (MSKCC), Briganti 2012, Briganti 2017, Briganti 2019, Partin 2016 and Yale models were evaluated using receiver-operating characteristic curve analysis (area under the curve [AUC]), calibration plots, and decision-curve analysis., Results: Overall, 1158 patients (9.6%) had LNI, with a mean of 17.7 and 3.2 resected and positive nodes, respectively. No significant differences in AUCs were observed between the MSKCC (0.79), Briganti 2012 (0.79), Partin 2016 (0.78), Yale (0.80), Briganti 2017 (0.81) and Briganti 2019 (0.76) models. A direct comparison of older models showed that better discrimination was achieved with the MSKCC and Briganti 2012 nomograms. A tendency for underestimation was seen for all the older models, whereas the Briganti 2017 and 2019 nomograms tended to overestimate LNI risk. Decision-curve analysis showed a net benefit for all models, with a lower net benefit for the Partin 2016 and Briganti 2019 models. ePLND-related complications were experienced by 1027 patients (8.9%), and 12.6% of patients with pN1 disease., Conclusions: The currently available nomograms have similar performances and limitations in the prediction of LNI. Miscalibration was present, however, for all nomograms showing a net benefit. In patients with only systematic biopsy, the MSKCC and Briganti 2012 nomograms were superior in the prediction of LNI., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)

Purpose: To elucidate early and long-term continence and patient comfort depending on type and duration of catheterization after robot-assisted radical prostatectomy., Methods: 198 patients were randomized prospectively into three groups (May 2016-July 2017): A transurethral catheter with micturition on postoperative day (POD) 5 was placed in the control group (TD5); a suprapubic tube (SPT) with micturition on POD 5 was placed in the group SD5 or with micturition on POD 2 in group SD2, respectively. Questionnaires were used for catheter-related satisfaction. Functional outcome analysis included residual volume analysis, uroflowmetry, IPSS, 12-h pad test, and daily pad use. Follow-up was conducted up to 12 months., Results: Postoperative comfort and catheter-related complications were similar in the three groups. However, on the day of catheter removal, continence was significantly better in the 12-h pad test for the SD2 group with 14 ml vs. 30 ml (TD5) and 24 ml (SD5), p = 0.007. Median residual urine volume between the groups was comparable with 17 ml in TD5, 7 ml in SD5, and 11 ml in SD2, (p = 0.07). Postoperative IPSS did not differ significantly in the follow-up period. After 4 weeks, 63% of the patients in SD2 were continent (no pad/day) compared to 33% in TD5 and 41% in SD5, p = 0.004. After 12 months, 76% were continent in TD5, 87% in SD5, and 94% in SD2, p = 0.023., Conclusions: Early micturition after SPT placement in robotic radical prostatectomy seems to be beneficial without an increased risk of complications.

Background: We previously reported a new post-radical prostatectomy (RP) prediction model for men with normal baseline erectile function (EF) using 90-d postoperative erection fullness to identify men who might benefit from early EF rehabilitation., Objective: To prospectively internally and externally validate the use of this risk assessment model in predicting 1- and 2-yr post-RP EF recovery., Design, Setting, and Participants: We randomly assigned 297 patients with a preoperative International Index of Erectile Function 5 score of 22-25 undergoing robot-assisted RP by a single surgeon to a training set and internal validation set at a ratio of 2:1. A prospective external validation set included 91 patients treated by five high-volume surgeons., Outcome Measurements and Statistical Analysis: Potency was defined as erections sufficient for intercourse. To predict 1- and 2-yr potency recovery, logistic regression models were developed in the training set based on 90-d erection fullness of 0-24% or 25-100%. The resultant models were applied to the internal and external validation sets to calculate risk scores for 1- and 2-yr potency for each patient. Predictive validity was assessed using receiver operating characteristic (ROC) curves., Results and Limitations: Percentage erection fullness was an independent predictor of 1- and 2-yr potency recovery in all data sets. Internal validation confirmed strong reliability in predicting 2-yr potency outcomes (area under the ROC curve [AUC] 0.87) and external validation illustrated similar reliability in predicting 1-yr potency outcomes (AUC 0.80). In the external validation, the model predicted a mean 1-yr potency recovery rate of 39.7% (standard deviation 3.2%), compared to the actual rate of 36.26%. Limitations include the short follow-up for this cohort., Conclusions: We present internal and external validation of a 90-d percentage erection fullness score, confirming that this metric is a robust predictor of post-RP EF recovery., Patient Summary: Percentage erection fullness at 3 mo after radical prostatectomy discriminates patients with a low or a high probability of recovery of erectile function (EF), which can facilitate identification of a need for early EF rehabilitation., (Copyright © 2018. Published by Elsevier B.V.)

Introduction: After the outbreak of COVID-19 unprecedented changes in the healthcare systems worldwide were necessary resulting in a reduction of urological capacities with postponements of consultations and surgeries., Material and Methods: An email was sent to 66 urological hospitals with focus on robotic surgery (RS) including a link to a questionnaire (e.g. bed/staff capacity, surgical caseload, protection measures during RS) that covered three time points: a representative baseline week prior to COVID-19, the week of March 16th-22nd and April 20th-26th 2020. The results were evaluated using descriptive analyses., Results: 27 out of 66 questionnaires were analyzed (response rate: 41%). We found a decrease of 11% in hospital beds and 25% in OR capacity with equal reductions for endourological, open and robotic procedures. Primary surgical treatment of urolithiasis and benign prostate syndrome (BPS) but also of testicular and penile cancer dropped by at least 50% while the decrease of surgeries for prostate, renal and urothelial cancer (TUR-B and cystectomies) ranged from 15 to 37%. The use of personal protection equipment (PPE), screening of staff and patients and protection during RS was unevenly distributed in the different centers-however, the number of COVID-19 patients and urologists did not reach double digits., Conclusion: The German urological landscape has changed since the outbreak of COVID-19 with a significant shift of high priority surgeries but also continuation of elective surgical treatments. While screening and staff protection is employed heterogeneously, the number of infected German urologists stays low., Competing Interests: The authors have declared that no competing interests exist.

Competing Interests: Erklärung zu finanziellen InteressenForschungsförderung erhalten: Ja; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: Ja; Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: Ja; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: Nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: Nein.Erklärung zu nichtfinanziellen InteressenAffiliated Board Member – ERUS Vorstandmitglied Deutsche Gesellschaft für Roboter-assistierte Urologie

Introduction: Robot-assisted simple prostatectomy (RASP) is a relatively new minimally invasive procedure for surgical treatment to manage symptomatic, therapy-refractory benign prostate hyperplasia (BPH) in prostate volumes >80 cm 3 . Thus, postoperative morbidity based on Clavien-Dindo and hematological parameters in RASP and open simple prostatectomy (OSP) procedures are examined., Patients and Methods: We retrospectively reviewed a total of 78 patients: 39 patients underwent RAPS and 39 OSP. The following parameters were statistically evaluated and compared: age, PSA value, prostate volume, ASA score, duration of hospital stay, operative time, Hb decrease on postoperative (po) day 1 and in the 5 five po days, CRP peak in the first 5 po days and transfusion rate., Results: The comparison between RASP and standard OSP showed no significant differences regarding the mean patient age (73 vs. 74 years; p =0.54), PSA values (7.7 vs. 10.7 ng/ml; p =0.17), ASA score (2.2 vs. 2.3; p =0.26) and prostate volume (130 vs. 113 cm 3 ; p =0.07). Patients in the RAPAE group had statistically significant longer surgery (178 vs. 110 min; p =<0.01) with a significantly smaller decrease in Hb on po day 1 (1.9 vs. 3.3 g/dl; p ≤0.01) and in the first 5 po days (2.4 vs. 4.2 g/dl; p ≤0.01), lower need for preserved blood (3% vs. 26%; p =0.01) and number of blood bags (0.1 vs. 1.3; p =0.01), a lower po Clavien-Dindo score (0.44 vs. 1.23; p =0.003) and lower CRP values (52 vs. 104 mg/l; p ≤0.01) in the first 5 po days., Conclusion: RASP is a safe procedure that offers the advantage of reduced blood loss and blood bag consumption and rare complications due to the minimally invasive surgical method. The OSP group showed an increased occurrence of complications due to bleeding, leading to prolonged hospitalization and significantly increased need for blood transfusion. The lesser increase of CRP in RASP group is a result of the lower invasiveness of the robot-assisted procedure.

Objectives: The aim of our study is to evaluate the role of preoperative quality of life (QL) as a possible risk factor for post robotic assisted radical prostatectomy (RARP) urinary incontinence. The secondary aim is to evaluate the possible effect of preoperative QL on post RARP lower urinary tract symptoms (LUTS) and erectile dysfunction (ED)., Methods and Materials: Between 2012 and 2017, all patients undergoing RARP for prostate cancer were enrolled. Patient's demographic, clinical, and histological characteristics were recorded. ED, LUTS, urinary incontinence, and QL were evaluated at baseline and postoperatively at 3, 6, and 12 months. Incontinence was evaluated with the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form questionnaire and QL with the EORTC QLQ-C30 global health score (QLQ-GHS). Multivariate logistic regression analysis was used to evaluate the risk of postoperative incontinence, moderate/severe incontinence, LUTS, and moderate/severe ED., Results: Overall 4,603 patients were enrolled. Incontinence rates at 3, 6, and 12 months were respectively 17%, 10%, and 8%. On multivariate analysis, QL was an independent predictor of early incontinence (QLQ-GHS:0.71, CI:0.59-0.86; P= 0.001), severe incontinence (QLQ-GHS:0.65, CI:0.49-0.97; P= 0.006), and LUTS (QLQ-GHS:0.48, CI:0.41-0.57; P= 0.001). Single center design may be considered a limitation., Conclusions: In our study a comprehensive evaluation of preoperative patient's QL, assessed by the EORTC QLQ-C30 questionnaire, can predict the early and long-term moderate/severe incontinence risk in RARP treated patients. Further studies should confirm our results., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Active surveillance is recommended for insignificant prostate cancer (PCa). Tools exist to identify suitable candidates using clinical variables. We aimed to develop and validate a novel risk score (NRS) predicting which patients are harbouring insignificant PCa., Methods: We used prospectively collected data from 8040 consecutive unscreened patients who underwent radical prostatectomy between 2006 and 2016. Of these, data from 2799 patients with Gleason 3 + 3 on biopsy were used to develop a multivariate model predicting the presence of insignificant PC at radical prostatectomy (ERSPC updated definition 3 : Gleason 3 + 3 only, index tumour volume < 1.3 cm 3 and total tumour volume < 2.5 cm 3 ). This was used to develop a novel risk score (NRS) which was validated in an equivalent independent cohort (n = 441). We compared the accuracy of existing predictive tools and the NRS in these cohorts., Results: The NRS (incorporating PSA, prostate volume, age, clinical T Stage, percent and number of positive biopsy cores) outperformed pre-existing predictive tools in derivation and validation cohorts (AUC 0.755 and 0.76, respectively). Selection bias due to analysis of a surgical cohort is acknowledged., Conclusions: The advantage of the NRS is that it can be tailored to patient characteristics and may prove to be valuable tool in clinical decision-making.

Purpose: To demonstrate the benefits of fluorescence-supported extended pelvic lymph node dissection (ePLND) compared to regular ePLND in robot-assisted radical prostatectomy., Methods: 120 patients with intermediate- or high-risk prostate cancer were prospectively randomized (1:1): in the intervention group, indocyanine green (ICG) was injected transrectally into the prostate before docking of the robot. In both groups, ePLND was performed including additional dissection of fluorescent lymph nodes (LN) in the ICG group., Results: After drop-out of two patients, 59 patients were allocated to the control (A) and intervention group (B) with a median PSA of 8,6 ng/ml. Median console time was 159 (A) vs. 168 (B) min (p = 0.20) with a longer time for ICG-ePLND: 43 (A) vs. 55 min (B) (p = 0.001). 2609 LN were found with significantly more LN after ICG-supported ePLND with a median of 25 vs. 17 LN in A (p < 0.001). Nodal metastases were detected in 6 patients in A (25 cancerous LN) vs. 9 patients in B (62 positive LN) (p = 0.40). In seven of nine patients, ICG-ePLND identified at least one cancer-positive LN (sensitivity 78%), 27 of 62 cancerous LN were fluorescent. Symptomatic lymphocele occurred in one patient in a and in three patients in b (p = 0.62). After a median follow-up of 22.9 months, PSA levels were similar., Conclusions: While ICG-ePLND seems to be beneficial for a better understanding of the lymphatic drainage and a more meticulous diagnostic approach, the sensitivity is not sufficient to recommend stand-alone ICG lymph node dissection.

Nocturia, defined as nocturnal micturition with a frequency of at least once per night, is one of the most frequent lower urinary tract symptoms in men with benign prostatic hyperplasia (BPH) and often causes them to consult a physician. Nocturia is often bothersome and responsible for increased morbidity and mortality. Nocturia can be caused by increased fluid intake, increased diuresis or decreased bladder capacity, either alone or in combination. The underlying pathophysiology of nocturia can only be detected by methodical evaluation of the patient. Bladder diaries for 3 days are an essential part of the assessment. Treatment goals include reducing the nocturnal voiding frequency to less than 2 episodes per night, increasing the duration of undisturbed sleep to more than 4 hours, restoring quality of life, and reducing morbidity as well as mortality. In patients with reduced functional bladder capacity, α-blockers, 5α-reductase inhibitors, phosphodiesterase type-5 inhibitors, plant extracts or prostate operations (e. g. TURP) have shown to significantly reduce nocturnal voiding frequency. If nocturnal polyuria causes or contributes to nocturia, as shown in up to 80 % of BPH patients with nocturia, the treatment goal is to reduce urine production during the night. Low nocturnal serum concentration of the antidiuretic hormone can be treated with desmopressin to be taken at bedtime. The risk of hyponatremia is reduced with the new low-dose desmopressin formulation, which can be used even in men older than 65 years of age. Drug combinations may be useful in men with a mixed pathophysiology of nocturia., Competing Interests: MO ist Berater, Referent und/oder Studienteilnehmer bei Apogepha Arzneimittel, Astellas, Dr. Schwabe GmbH, Duchesnay, Ely Lilly, Ferring, GlaxoSmithKline, Pfizer und Recordati. BF, JZ und JHW: keine., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: To compare the outcomes of robot-assisted (RAPN) and open partial nephrectomy (OPN) for completely endophytic renal tumors., Methods: Consecutive patients undergoing OPN or RAPN for entirely endophytic tumors in four high-volume centers between 2008 and 2016 were identified. Endophytic masses were identified based on sectional imaging. Patient characteristics and surgical outcome were compared using Mann-Whitney-U-test and chi-squared-tests. Uni- and multivariate analyses were performed to identify predictors of TRIFECTA achievement and excisional volume loss., Results: Out of 1128 patients, 10.9% (64) of RAPN and 13.9% (76) of OPN underwent surgery for entirely endophytic tumors. Operative time was longer for RAPN (169 vs 140 min, P = 0.03) while ischemia time was shorter (13 vs 18 min, P = 0.001). Complication rates were comparable (21% OPN vs 22% RAPN, P = 0.91) and TRIFECTA achievement was not different between the groups (68% OPN vs 75% RAPN, P = 0.39). In multivariate analyses type of surgery was not associated with TRIFECTA achievement or excisional volume loss. Here, only tumor complexity (OR 0.48, P = 0.001) and size (OR 1.01, P = 0.002) were independent predictors., Conclusion: For entirely endophytic tumors, both RAPN and OPN offer good TRIFECTA achievement. This encourages the use of NSS even for these highly complex tumors using the surgeon's preferred approach., (© 2018 Wiley Periodicals, Inc.)

Purpose: To evaluate the differences between the old and the new Gleason score classification systems in upgrading and downgrading rates., Materials and Methods: Between 2012 and 2015, we identified 9703 patients treated with retropubic radical prostatectomy (RP) in four tertiary centers. Biopsy specimens as well as radical prostatectomy specimens were graded according to both 2005 Gleason and 2014 ISUP five-tier Gleason grading system (five-tier GG system). Upgrading and downgrading rates on radical prostatectomy were first recorded for both classifications and then compared. The accuracy of the biopsy for each histological classification was determined by using the kappa coefficient of agreement and by assessing sensitivity, specificity, positive and negative predictive value., Results: The five-tier GG system presented a lower clinically significant upgrading rate (1895/9703: 19,5% vs 2332/9703:24.0%; p = .001) and a similar clinically significant downgrading rate (756/9703: 7,7% vs 779/9703: 8%; p = .267) when compared to the 2005 ISUP classification. When evaluating their accuracy, the new five-tier GG system presented a better specificity (91% vs 83%) and a better negative predictive value (78% vs 60%). The kappa-statistics measures of agreement between needle biopsy and radical prostatectomy specimens were poor and good respectively for the five-tier GG system and for the 2005 Gleason score (k = 0.360 ± 0.007 vs k = 0.426 ± 0.007)., Conclusions: The new Epstein classification significantly reduces upgrading events. The implementation of this new classification could better define prostate cancer aggressiveness with important clinical implications, particularly in prostate cancer management., (Copyright © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Purpose: To demonstrate the surgical feasibility of robot-assisted partial nephrectomy for complex renal masses with comparison of low/intermediate risk versus high-risk tumors according to the PADUA score., Methods: Since 2008, 538 robot-assisted partial nephrectomies were performed at three German robotic centers. Both the MIC (margin, ischemia, complications) criteria and trifecta were applied., Results: 60.1% of the tumors were of low and intermediate complexity (PADUA score 6-9, n = 326, group A), while 39.9% were highly complex (n = 212, score ≥ 10, B). Median clinical tumor size was 28 in A versus 37 mm in B (p < 0.001). There was no significant difference in terms of operative time (160 vs. 163 min, p = 0.20); ischemia time was slightly longer for B (11 vs. 12 min, p < 0.001). There were no significant differences for intra- (3.4%, A, vs. 6.6%, B, p = 0.10) or postoperative (21.5%, A, vs. 25.5%, B, p = 0.30) complication rates. There was a median eGFR decrease of - 9.4 (A) versus - 15.1 (B) ml/min (p < 0.001) on discharge. Histopathology revealed an R1 margin rate of 3.4% for the low/intermediate versus 6.1% for the high complexity group (p = 0.14). MIC criteria were fulfilled in 81.9% (A) versus 75.5% (B, p = 0.11) and trifecta criteria in 74.2% (A) versus 68.93% (B, p = 0.26)., Conclusions: Complication rates, histopathology results as well as quality criteria as indicated by MIC and trifecta were similar for high and low complexity groups. Therefore, robot-assisted partial nephrectomy is a safe and feasible option also in highly complex tumors.

Purpose: To evaluate the impact of the type of urinary diversion (suprapubic vs. transurethral catheterization) on patients' postoperative pain after radical prostatectomy, development of bacteriuria and long-term functional results., Methods: A randomized, prospective clinical trial was performed including 160 patients who underwent robot-assisted radical prostatectomy after randomization into two groups: intraoperatively, a transurethral catheter (control group) or an additional suprapubic tube (with removal of the transurethral catheter in the morning of postoperative day 1; intervention group) was placed. Primary study endpoint was postoperative pain objectified by the numeric rating scale questionnaire. Secondary endpoints were bacteriuria after catheter removal and functional outcomes after up to 2 years of follow-up., Results: There were no significant differences in demographic and perioperative data. Starting on postoperative day 2, patients in the suprapubic diversion group had significantly less pain on every time point preceding the removal of the catheter compared to the control cohort with a median overall numeric rating score on postoperative day 1-4 of 2.4 points in the transurethral versus 1.3 in the intervention group (p = 0.012). No statistical difference was found in postoperative bacteriuria and complications as well as in functional results, quality of life and incontinence rates after a median follow-up of 22 months., Conclusions: Suprapubic drainage in robot-assisted radical prostatectomy shows significantly decreased pain levels during the catheterization period compared to the transurethral diversion without compromising long-term functional results. Intraoperative placement of a suprapubic tube should be discussed as a standard procedure for further improvement of patients' postoperative comfort.

Objective: The objective of this study was to assess the surgical, oncological and short-term functional outcomes in patients undergoing salvage robot-assisted radical prostatectomy (SRARP) for the treatment of radiation-resistant prostate cancer., Patients and Methods: The records of 3,500 men who underwent RARP from February 2006 to July 2011 were retrospectively reviewed. All peri- and postoperative data were recorded prospectively in our database. A total of 13 patients (0.37%) who had undergone SRARP for the treatment of radiation-resistant prostate cancer were identified., Results: The primary treatment was external beam radiotherapy in 7 patients (53.8%) and brachytherapy in 6 patients (46.2%). The interval from radiotherapy to biochemical recurrence (BCR) varied from 12 to 108 months (median 48.9). Neurovascular bundle preservation was performed in 3 patients (23.1%). No intraoperative or major complications were encountered. Minor complications were encountered in 4 patients (30.7%). At 12 months, 7 patients were continent (53.8%), 3 exhibited mild incontinence (23.1%) and 3 (23.1%) were incontinent. Regarding potency, none of the patients were potent at 6 months, but 3 patients (23.1%) were potent at 1 year. Regarding BCR, 3 of the patients (23.1%) never reached a prostate-specific antigen nadir of zero, and during the follow-up period only 3 patients (23.1%) exhibited BCR. No disease-specific mortality was evident during follow-up., Conclusions: Although early in its development, it appears that SRARP is technically feasible and offers satisfactory surgical, oncological and short-term functional outcomes., (Copyright © 2013 S. Karger AG, Basel.)

Peritoneal dissemination of prostate cancer (PCa) with the absence of other metastases is extremely rare. Atypical sites of metastatic disease, for example the peritoneum, are only a recognized finding at autopsy. Herein, we report a case of peritoneal dissemination of a PCa, with the absence of lymph node, skeletal, or visceral metastases in a patient scheduled to undergo robot-assisted laparoscopic prostatectomy.

Introduction: The objective of this study is to evaluate the surgical, oncological and short-term functional outcomes in patients with a pathologic prostate specimen weight ≥100 g versus patients with a pathologic prostate specimen weight ≤50 g undergoing robot-assisted radical prostatectomy (RARP)., Patients and Methods: The records of 4,000 men who underwent RARP from February 2006 to April 2012 were reviewed retrospectively. A total of 185 men had a pathologic prostate specimen weight ≥100 g (group A). A matched pairs analysis was performed using our database to identify men with a pathologic prostate specimen weight ≤50 g but with equivalent clinicopathologic characteristics to serve as the control group (group B)., Results: Our results indicated that although the intraoperative results were more than satisfying in patients with large glands, there is a significant increase in blood loss, operative time needed, increased need for bladder neck reconstruction as well as an increase in intraoperative complications. Nevertheless, patients with large glands exhibit less aggressive tumors, less positive surgical margins and a lower incidence of biochemical recurrence. Regarding functional outcomes, patients with larger glands had no difference regarding continence rates when compared to patients with smaller glands but exhibited significantly lower potency rates., Conclusions: Although RARP in patients with a pathologic prostate specimen weight ≥100 g is technically challenging, in experienced hands it can be considered a safe procedure with excellent surgical, oncological and functional outcomes. Nevertheless, this conclusion is limited, in that it is from a single institution with a large case volume and may not be reflective of outcomes at centers with smaller volumes and less experience., (Copyright © 2012 S. Karger AG, Basel.)