Systematic Review: The Learning Curve for Robot-Assisted Radical Cystectomy-What Do We Know?

Background: The aim of this systematic review is to assess the robot-assisted radical cystectomy (RARC) learning curve (LC), which is important to consider in both risk-benefit assessment and training. Materials and Methods: We performed a systematic literature search using two databases (Medline and Scopus) with the search query "learning AND cystectomy" and included all articles containing data on the assessment of the RARC LC. Our primary outcome was the surgeons' experience (a number of performed procedures) required to achieve the LC plateau. The secondary outcomes related to the methods for assessing the relevant LC. Results: Between 9 and 50 procedures were required to reduce the operation time significantly. The data on estimated blood loss during RARC are somewhat controversial. To optimize the lymph node (LN) yield, it was necessary to treat between 20 and 50 patients. The LC for positive surgical margin was described only in one study, it was completed after 24-30 cases. Between 10 and 15 cases were necessary to reduce length of stay (LOS). Complications became less frequent after 10 to 75 patients but there was no clear plateau in the figures. Conclusions: Based on the relevant assessment criteria, the RARC LC length varies from 10 to 50 cases. The most common criteria for evaluating the learning experience include operation time and the LN yield. Blood loss, length of stay, and complications rate show variable outcomes and may be harder to use systematically as a means of LC assessment.

Retrograde intrarenal surgery versus percutaneous nephrolithotomy in larger kidney stones. Could SuperPulsed Thulium-fiber laser change the game?

INTRODUCTION: The aim of this article was to compare retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) efficacy and safety with SuperPulsed Thulium-fiber laser (SP TFL) for stones 20 mm and larger. MATERIAL AND METHODS: Patients with large kidney stones (20 mm and larger) were recruited to undergo PCNL or RIRS with SP TFL lithotripsy. Both groups were comparable in terms of stone size and density, operation time, laser-on time (LOT), stone-free rate, residual fragments and complication rate. Stone retropulsion and visibility were assessed based on the surgeon's feedback using Likert scales. RESULTS: A total of 14 and 56 patients were included in the RIRS and PCNL groups, respectively. The mean stone density was 833.8 ±298.3 HU in the RIRS group and 882.3 ±408.5 HU in the PCNL group (p = 0.072). The median LOT was 11.7 (10.0-15.5) min for RIRS and 10.0 (6.0-12.1) min for PCNL (p = 0.207). The median total energy for stone ablation was 13.8 (11.8-25.0) kJ for RIRS and 12.0 (7.0-20.1) kJ for PCNL (p = 0.508). The median ablation speed was 3.9 (3.9-5.7) mm3/sec for RIRS and 5.0 (4.6-11.3) mm3/sec for PCNL (p = 0.085). We found a significant correlation between retropulsion and the type of surgery performed: with higher retropulsion in the PCNL (r = 0.298 with p = 0.012). The stone-free rate at 3-months was 85.7% in RIRS and 89.3% in PCNL (p = 0.505). CONCLUSIONS: SP TFL is a safe and effective modality for lithotripsy for both, RIRS and PCNL, achieving minimal retropulsion and good visibility. No discrepancies in procedure duration, complications, or LOT were identified between the different modalities.

Superpulse thulium fiber laser lithotripsy: an in vitro comparison of 200 µm and 150 µm laser fibers.

PURPOSE: To investigate the thermal effects, stone retropulsion and ablation rate of SuperPulse Thulium-fiber laser (SP TFL) with two different surgical fibers of 200 and 150 µm in diameter. METHODS: SP TFL (NTO IRE-Polus, Fryazino, Russia) performance with 200 and 150 µm fibers (NTO IRE-Polus, Fryazino, Russia) was evaluated. Before each test, the laser fiber was cleaved, and the power measurement was taken to verify the actual laser output power. To compare the laser fibers in well-controlled environments, a number of setups were used to assess retropulsion, ablation efficacy, fiber burnback, energy transmission, and safety. RESULTS: Power measurements performed before each test revealed a 4.7% power drop for a 200 µm fiber SP TFL (14.3 ± 0.5 W) and 7.3% power drop for a 150 µm fiber SP TFL (13.9 ± 0.5 W) versus the nominally indicated power (15.0 W). Retropulsion with the TFL was minimal and comparable between fibers. We found no clinically relevant temperature differences between SP TFL with either 200 or 150 µm fibers. The ablation efficacy tended to be comparable under most parameters. Yet, we did observe a decreased diameter of residual fragments after the ablation with a 150 µm fiber. CONCLUSION: The smaller fiber (150 µm) is not inferior to 200 µm fiber in terms of fiber burnback, retropulsion, safety, and ablation rate. Moreover, it has the potential to decrease the diameter of fragments during lithotripsy, which may facilitate dusting during RIRS.

Superpulsed Thulium Fiber Laser for Stone Dusting: In Search of a Perfect Ablation Regimen-A Prospective Single-Center Study.

Objective: To compare the efficacy of the standard and higher frequency regimens for superpulsed thulium fiber laser (SP TFL) retrograde intrarenal surgery (RIRS). Materials and Methods: A prospective study of patients with renal calculi of 10-30 mm was performed. For RIRS, we used the SP TFL (NTO IRE-Polus, Russia) and a 9.5F flexible ureteroscope with 270° deflection and 3.6F working channel. Retropulsion and visibility were assessed based on the surgeon's feedback using three-point Likert scales. The stone-free rate was assessed at 3 months with CT. Results: A total of 40 patients were included in the study with a mean age of 56 years, mean stone density of 880 ± 381 HU, mean stone size of 16.5 ± 6.8 mm, and median stone volume of 883 (interquartile range 606-1664) mm3. Both ablation efficacy and speed were higher in the 200-Hz mode (2.7 J/mm3vs 3.8 J/mm3 and 5.5 mm3/second vs 8.0 mm3/second, respectively); moreover, the higher frequency correlated with increased ablation speed (r = -0.21, p = 0.019). However, both increased energy and frequency did not lead to increase of laser-on time or intraoperative complication rates. Conclusions: SP TFL is able to effectively disintegrate stones during RIRS with minimal complication rates. The use of higher frequency regimens showed higher efficacy and ablation speed and was not associated with increased complication rates.

Monopolar enucleation versus transurethral resection of the prostate for small- and medium-sized (< 80 cc) benign prostate hyperplasia: a prospective analysis.

AIM: To assess efficacy and safety of monopolar enucleation of the prostate (MEP) and to compare it with the current treatment standard for medium-sized prostates, < 80 cc, transurethral resection of the prostate (TURP). METHODS: A prospective analysis patients undergoing a surgical procedure for their diagnosis of BPH (benign prostatic hyperplasia) (IPSS > 20, Qmax < 10; prostate volume < 80 cc) was performed. IPSS, Qmax were assessed preoperatively, at 6 and 12 months postoperatively. The complications were classified according to the modified Clavien-Dindo grading system. RESULTS: A total of 134 patients were included in the study: 70 underwent MEP and 64 - TURP for BPH (mean prostate volumes were comparable with p = 0.163). The mean surgery time was 44 min in the TURP group and 48.2 min in the MEP group, (p = 0.026). Catheterization time for MEP was 1.7 and 3.2 days for TURP (p < 0.001). Hospital stay for MEP was 3.2 days vs. 4.8 days for TURP (p < 0.001). Both techniques shown comparable efficiency in benign prostatic obstruction relief with IPSS drop in MEP from 23.1 to 5.9 and in TURP group from 22.8 to 7.3, whereas Qmax increased from 8.2 to 20.5 after MEP and from 8.3 and 19.9 after TURP. Urinary incontinence rate after catheter removal in TURP group was 9.0% and 7.8% in MEP group, at 1 year follow-up, it was 1.4% and 3.1% in MEP and TURP, respectively (p = 0.466). CONCLUSIONS: Our experience demonstrated that MEP is an effective and safe BPH treatment option combining the efficacy of endoscopic enucleation techniques and accessibility of conventional TURP.

Novel Thulium Fiber Laser for Enucleation of Prostate: A Retrospective Comparison with Open Simple Prostatectomy.

INTRODUCTION: The objective of this study was to assess the efficacy and safety of novel thulium fiber laser enucleation of the prostate (ThuFLEP) vs conventional open simple retropubic prostatectomy (OP) for large volume benign prostatic hyperplasia (BPH). METHODS: We performed a retrospective review of patients who underwent surgical treatment for large volume BPH (>80 cc) from 2015 to 2017. Preoperative patient examination included the assessment of functional parameters: International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urine flow rate (Qmax), and postvoid residual urine volume. The hemoglobin level was measured before and after the operation. RESULTS: A total of 130 patients were included in the study. Of these, 40 patients underwent OP, and 90 patients underwent ThuFLEP. Groups were similar in terms of preoperative functional parameters (IPSS, QoL, and Qmax). The mean operative time was comparable for both procedures (p = 0.285) as well as the mass of adenomatous tissue resected (p = 0.412). Resection speed was comparable (OP-0.9 vs ThuFLEP-1.0 g/min, p = 0.52). Patients in OP had significantly longer catheterization time and length of hospital stay (9.0 days vs 3.3 days, p < 0.001). At 6 months, stress urinary incontinence rate were 1.1% after ThuFLEP and 2.5% after OP. CONCLUSIONS: Despite the equally high efficacy of both modalities for infravesical obstruction due to BPH, ThuFLEP is a minimally invasive modality that is associated with a shorter hospital stay, a significantly greater return to normal activities, and a considerable reduction in rehabilitation time. Our results demonstrated that the ThuFLEP is a highly efficacious, minimally invasive modality for the management of BPH in large volume glands (>80 cc).