Stratification of Potency Outcomes Following Robot-Assisted Laparoscopic Radical Prostatectomy Based on Age, Preoperative Potency, and Nerve Sparing.

Introduction: To identify factors affecting potency and to predict ideal patient subgroups who will have the highest chance of being potent after robot-assisted laparoscopic prostatectomy (RALP) based on nerve sparing (NS). Materials and Methods: Analysis of 7268 patients who underwent RALP between 2008 and 2018 with a minimum of 12 months of follow-up was performed. The patients were then categorized into four separate neurovascular bundle-sparing groups (NVB 1-4). A Cox regression analysis was used to determine the independent factors predicting potency outcomes. Cumulative incidence functions were used to depict the probability and time to potency between the NS groups stratified by age and preoperative sexual health inventory in men (SHIM). Results: Cox regression analysis of age, preoperative SHIM score, and grades of NS significantly predicted potency outcomes post-RALP. Patients with SHIM score ≥22 had a better chance of potency vs patients with SHIM <17 (odds ratio [OR]: 1.69, confidence interval [CI]: 1.47-1.79). NVB1 had better potency vs NVB4 (OR: 3.1, CI: 2.51-3.83). Patients <55 years with NVB1 and no preoperative erectile dysfunction had the best potency rates of 92.5%. However, we did not see any statistical difference between NVB2 and NVB3 in this group, implying that in patient groups with SHIM ≥22 and age <55, NVB1 provided the best chance of potency recovery. As age increased and preoperative SHIM worsened, the curves corresponding to NVB 2 and 3 showed significant differences, suggesting that NVB 2 and 3 may be predictive in unfavorable age and preoperative SHIM groups, especially NVB 2 > NVB 3. Conclusions: Preoperative SHIM, age, and NS are the most influential factors for potency recovery following RALP. Patients with good baseline sexual function had similar postoperative potency, irrespective of their grades of partial NS. In patients with decreased baseline SHIM and older age, a higher grade of partial NS resulted in a significantly better potency compared with a lower grade of partial nerve spare.

A Predictive Preoperative and Postoperative Nomogram for Postoperative Potency Recovery after Robot-Assisted Radical Prostatectomy.

PURPOSE: Prediction of potency recovery following robot-assisted radical prostatectomy (RARP) is useful for better patient counseling and postoperative treatment strategies. In this study we propose a preoperative and postoperative nomogram to predict postoperative potency recovery following RARP. MATERIALS AND METHODS: Patients from development set (6,502) were selected to develop the nomograms, and patients in validation set (2,706) were used for validation. Cox regression models were fitted on the development cohort to predict potency recovery after RARP using as prognostic factors the covariates selected. Two nomograms were drawn using the regression coefficients of the preoperative and postoperative Cox models. RESULTS: The discrimination ability of the preoperative model was evaluated on the development cohort using the receiver operator curves estimated at 3, 6, 12 and 24 months. The AUC at these time points was 0.726, 0.734, 0.754, and 0.778, respectively. The areas under the curve of the postoperative model at 3, 6, 12 and 24 months were 0.746, 0.756 and 0.777, and 0.801, respectively. Preoperative and postoperative predictive models were validated using a separate set of 2,706 patients. The AUCs of the preoperative model at 3, 6, 12 and 24 months were 0.789, 0.772, 0.768, and 0.778, respectively. The ROC curves of the postoperative model at 3, 6, 12 and 24 months with AUCs of 0.807, 0.797, 0.793 and 0.798, respectively. Along with age and preoperative sexual function, nerve-sparing technique determines the potency outcomes justifying better AUC for postoperative model vs the preoperative model. CONCLUSIONS: The above nomograms help us to predict with good accuracy the probability of potency recovery within 3, 6, 12 and 24 months following surgery taking into consideration preoperative and postoperative factors. This is a novel tool for the care giver to predict realistic expectation of potency outcomes to the patients, while preoperative and immediate postoperative counseling.

Stratification of Potency Outcomes Following Robot-Assisted Laparoscopic Radical Prostatectomy Based on Age, Preoperative Potency, and Nerve Sparing.

Introduction: To identify factors affecting potency and to predict ideal patient subgroups who will have the highest chance of being potent after robot-assisted laparoscopic prostatectomy (RALP) based on nerve sparing (NS). Materials and Methods: Analysis of 7268 patients who underwent RALP between 2008 and 2018 with a minimum of 12 months of follow-up was performed. The patients were then categorized into four separate neurovascular bundle-sparing groups (NVB 1-4). A Cox regression analysis was used to determine the independent factors predicting potency outcomes. Cumulative incidence functions were used to depict the probability and time to potency between the NS groups stratified by age and preoperative sexual health inventory in men (SHIM). Results: Cox regression analysis of age, preoperative SHIM score, and grades of NS significantly predicted potency outcomes post-RALP. Patients with SHIM score ≥22 had a better chance of potency vs patients with SHIM <17 (odds ratio [OR]: 1.69, confidence interval [CI]: 1.47-1.79). NVB1 had better potency vs NVB4 (OR: 3.1, CI: 2.51-3.83). Patients <55 years with NVB1 and no preoperative erectile dysfunction had the best potency rates of 92.5%. However, we did not see any statistical difference between NVB2 and NVB3 in this group, implying that in patient groups with SHIM ≥22 and age <55, NVB1 provided the best chance of potency recovery. As age increased and preoperative SHIM worsened, the curves corresponding to NVB 2 and 3 showed significant differences, suggesting that NVB 2 and 3 may be predictive in unfavorable age and preoperative SHIM groups, especially NVB 2 > NVB 3. Conclusions: Preoperative SHIM, age, and NS are the most influential factors for potency recovery following RALP. Patients with good baseline sexual function had similar postoperative potency, irrespective of their grades of partial NS. In patients with decreased baseline SHIM and older age, a higher grade of partial NS resulted in a significantly better potency compared with a lower grade of partial nerve spare.

COVID-19 model-based practice changes in managing a large prostate cancer practice: following the trends during a month-long ordeal.

Coronavirus (COVID-19) has been a life-changing experience for both individuals and institutions. We describe changes in our practice based on real-time assessment of various national and international trends of COVID-19 and its effectiveness in the management of our resources. Initial risk assessment and peak resource requirement using the COVID-19 Hospital Impact Model for Epidemics (CHIME) and McKinsey models. Strengths, weaknesses, opportunities, and threats (SWOT) analysis of our practice's approach during the pandemic. Based on CHIME the community followed 60% social distancing, the number of expected new patients hospitalized at maximum surge would be 401, with 100 patients requiring ventilator support. In contrast, when the community followed 15% social distancing, the maximum surge of hospitalized new patients would be 1823 and 455 patients would require a ventilator. on April 15, the expected May requirement of ICU beds at peak would be 68, with 61 patients needing ventilators. The estimated surge numbers improved throughout April, and on April 22 the expected ICU bed peak in May would be 11.7, and those requiring ventilator would be 10.5. Simultaneously, within a month, our surgical waitlist grew from 585 to over 723 patients. Our SWOT analysis revealed our internal strengths and inherent weakness, relevant to the pandemic. A graded and a guarded response to this type of situation is crucial in managing patients in a large practice.

The surgical learning curve for salvage robot-assisted radical prostatectomy: a prospective single-surgeon study.

BACKGROUND: The aim of this study was to report the overall results and the learning curve (LC) in salvage robot-assisted radical prostatectomy (sRARP) patients, in terms of morbidity, oncological and functional outcomes in a single surgeon tertiary-referral center. METHODS: One hundred and twenty patients underwent sRARP by a single surgeon (V.P.) from 2008 to 2018. To assess the trends in the learning experience they were sub-divided in 4 groups of 30 consecutive patients based on date of surgery. The Kaplan-Meier method and regression models were used to identify survival estimations and predictors of potency, continence and biochemical failure (BCF) at 12 months. RESULTS: As the learning experience for sRALP increased operative time (OT) was significantly shorter (from 139.5 to 121 minutes) and the amount of nerve-sparing (NS) undertaken increased (from 46% to 80%). While complications rate remained stable, estimated blood loss (EBL) and radiographic anastomotic leaks (RAL) decreased through the groups (from 124 to 69 ml and 40% to 16,7%, respectively). BCF and continence rates at 12 months after sRARP were similar among groups (23-36% and 36,7-50%, respectively) and chance of potency rates tended to increase (from 3.3% to 16-23%) but was not statistically significant. In a multivariate analysis, predictors for BCF were PSM and GS 8-10. Non-radiation primary treatment was the unique predictor of continence at 12 months after sRARP. CONCLUSIONS: Our data may suggest a decreasing trend in terms of OT and EBL through the sRARP learning curve. While morbidity remained stable through the time, RAL trended towards a decline. A higher degree of NS was observed through the groups and there was a slight correlation trend between surgical expertise and potency recovery. PSM and GS 8-10 were predictors of BCF and non-radiation primary treatment predicted a better continence after sRARP.

Trends in clinical and oncological outcomes of robot-assisted radical prostatectomy before and after the 2012 US Preventive Services Task Force recommendation against PSA screening: a decade of experience.

OBJECTIVE: To assess the influence of the 2012 US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen (PSA)-based screening on oncological and functional outcomes following robot-assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: We retrospectively analysed patients who underwent RALP between 2008 and 2018 with a minimum of 12-month follow-up from a prospectively collected institutional review board-approved database. The impact of the USPSTF recommendation against PSA screening on our surgical outcomes was assessed using a logistic regression model using two groups comprising patients treated before/after the USPSTF statement and indicating time trends for each successive year. RESULTS: The mean preoperative PSA increased from 6.0 to 7.4 ng/mL after the USPSTF recommendation. We detected statistically significant time-trend changes after 2012, including an increase in the positive slope of Gleason ≥3 + 4 or ≥pT3 disease. We detected a fall in bilateral full nerve-sparing and an increase in partial nerve-sparing. The total positive surgical margin (PSM) rate increased after the USPSTF recommendation; however, PSM rates pertinent to each pathological stage did not change significantly after 2012. There was a significant negative trend change in the postoperative 12-month continence and potency rates, indicating a breakpoint in functional outcomes after 2012. We detected a 1.7-fold increase in 12-month biochemical recurrence (BCR) rates. The 12-month BCR, potency and continence rates were maintained in young (<55 years) patients with a Sexual Health Inventory for Men score >22 and low-volume disease. CONCLUSION: Since the USPSTF's recommendation in 2012, we have seen a significant increase in the incidence of high-risk disease that has forced us to modify our approach to the procedure and the grade of nerve-sparing used, leading to a wider resection, in order to reduce PSMs. This has led to a decrease in postoperative functional recovery. Patients with favourable characteristics had good outcomes before and after the USPSTF's recommendation, implying that the quality of surgery did not change over time.

Changing clinical trends in 10 000 robot-assisted laparoscopic prostatectomy patients and impact of the 2012 US Preventive Services Task Force's statement against PSA screening.

OBJECTIVES: To evaluate the clinical trend changes in our robot-assisted laparoscopic prostatectomy (RALP) practice and to investigate the effect of 2012 US Preventive Services Task Force (USPSTF) statement against PSA screening on these trends. PATIENTS AND METHODS: Data of 10 000 RALPs performed by a single surgeon between 2002 and 2017 were retrospectively analysed. Time trends in successive 1000 cases for clinical, surgical and pathological characteristics were analysed with linear and logistic regression. Time-trend changes before and after the USPSTF's statement were compared using a logistic regression model and likelihood-ratio test. RESULTS: Unfavourable cancer characteristics rate, including D'Amico high risk, pathological non-organ-confined disease and Gleason score ≥4+4 increased from 11.5% to 23.3%, 14% to 42.5%, and 7.7% to 20.9%, respectively, over time (all P < 0.001). Significant time-trend changes were detected after the USPSTF's statement with an increase in the positive trend of Gleason ≥4+4 and increase in the negative trends of Gleason ≤3+4 tumours. There was a significant negative trend in the rate of full nerve-sparing (NS) with a decrease from 59.3% to 35.7%, and a significant positive trend in partial NS with an increase from 15.8% to 62.5% over time (both P < 0.001). The time-trend slope in 'high-grade' partial NS significantly decreased and 'low-grade' partial NS significantly increased after the USPSTF's statement. The overall positive surgical margin rate increased from 14.6% to 20.3% in the first vs last 1000 cases (P < 0.001), with a significant positive slope after the USPSTF's statement. CONCLUSIONS: The proportion of high-risk patients increased in our series over time with a significant impact of the USPSTF's statement on pathological time trends. This stage migration resulted in decreased utilisation of high-quality NS and increased performance of poor-quality NS.

Comparison of surgical, functional, and oncological outcomes of open and robot-assisted partial nephrectomy.

BACKGROUND: We aimed to compare the surgical, oncological, and functional outcomes of robot-assisted partial nephrectomy (RAPN) with open partial nephrectomy (OPN) in the management of small renal masses. MATERIALS AND METHODS: Between 2009 and 2013, a total of 46 RAPN patients and 20 OPN patients was included in this study. Patients' demographics, mean operative time, estimated blood loss (EBL), warm ischemia time (WIT), length of hospital stay, pre- and post-operative renal functions, complications and oncological outcomes were recorded, prospectively. RESULTS: Mean tumor size was 4.04 cm in OPN group and 3.56 cm in RAPN group (P = 0.27). Mean R.E.N.A.L nephrometry score was 6.35 in OPN group and 5.35 in RAPN group (P = 0.02). The mean operative time was 152 min in OPN group and 225 min in RAPN group (P = 0.006). The mean EBL in OPN and RAPN groups were 417 ml and 268 ml, respectively (P = 0.001). WIT in OPN group was significantly shorter than RAPN group (18.02 min vs. 23.33 min, P = 0.003). The mean drain removal time and the length of hospital stay were longer in OPN group. There were no significant differences in terms of renal functional outcomes and postoperative complications between groups. CONCLUSION: Minimally invasive surgical management of renal masses with RAPN offers better outcomes in terms of EBL and length of stay. However, the mean operative time and WIT were significantly shorter in OPN group. RAPN is a safe and effective minimally invasive alternative to OPN in terms of oncological and functional outcomes.

Short stay pyeloplasty with transverse dorsal lumbotomy incision: our 10-year experience.

OBJECTIVES: To review our long-term results with a modified dorsal lumbotomy (DL) approach and evaluate its role as a minimally-invasive alternative for the surgical management of ureteropelvic junction obstruction (UPJO). METHODS: Fifty-nine consecutive children (42 males, 17 females, median age: 5.7 years) underwent pyeloplasty with transverse DL (TDL) between 1999 and 2008. Kidney stones, solitary kidney, and bilateral UPJ obstruction was present in 6, 3, and 5 children, respectively. Forty-nine and 10 children received stented dismembered pyeloplasty and Y-V plasty, respectively. Information on the duration of surgery, length of hospital stay, length of time to return to unrestricted activity, and per/postoperative complications was recorded. Children were followed up postoperatively with urinalysis and ultrasonography (US) at first month, diuretic renogram or intravenous urography (IVU) or both at sixth month, and yearly thereafter with US and renal scintigraphy for the emergence of recurrent clinical symptoms, deterioration of differential renal function, or increase in hydronephrosis. RESULTS: Median operative time was 78 minutes and median incision length ranged between 3 and 5 cm for all age groups. All children tolerated liquid diet within the evening of surgery and returned to unrestricted activity within 48 hours. Eight-eight percent of all patients were discharged within 2 days, and 88% of children operated after 2004 were discharged in less than 30 hours. Recurrent UPJO was not evident in any case with a median follow-up of 56 months. CONCLUSIONS: TDL provides excellent exposure for UPJO repair with a cosmetically appealing scar while maintaining a minimal convalescence advantage. It is particularly beneficial in bilateral pyeloplasty as synchronous bilateral repair can be performed without repositioning the patient.