Outcome benefits of upfront cytoreductive nephrectomy for patients with metastatic renal cell carcinoma: An analysis of the TriNetX database.

BACKGROUND: The role of upfront cytoreductive nephrectomy remains debatable in the present era of tyrosine kinase inhibitors and immune checkpoint inhibitors. Here, we aimed to evaluate the outcomes of metastatic renal cell carcinoma patients treated with upfront CN and modern systemic therapies. METHODS: Using the TriNetX network database, we identified patients, in the period from 2008 to 2022, who were diagnosed with metastatic renal cell carcinoma, receiving first-line systemic therapies with tyrosine kinase inhibitors or immune checkpoint inhibitors. Their overall survivals were evaluated using the Kaplan-Meier method as well as multivariable regressions. RESULTS: We identified 11,094 patients with metastatic renal cell carcinoma. Of them, 2,914 (43%) patients in the tyrosine kinase inhibitor cohort (n = 6,779), and 1,884 (43.7%) in the immune checkpoint inhibitors cohort (n = 4315) underwent upfront cytoreductive nephrectomy. Those receiving upfront cytoreductive nephrectomy showed survival advantages with either tyrosine kinase inhibitor (Hazard ratio 0.722, 95% Confidence interval 0.67-0.73, p<0.001) or immune checkpoint inhibitors (Hazard ratio 65.1, 95% Confidence interval 0.59-0.71, p<0.001). In multivariable analysis, upfront cytoreductive nephrectomy was a factor for improved OS in both cohorts: tyrosine kinase inhibitors (Hazard ratio 0.623, 95% Confidence interval 0.56-0.694, p<0.001) and immune checkpoint inhibitors cohort (Hazard ratio 0.688, 95% Confidence interval 0.607-0.779, p<0.001). CONCLUSIONS: Upfront cytoreductive nephrectomy was associated with an improved overall survival for patients with metastatic renal cell carcinoma receiving either first-line tyrosine kinase inhibitors or immune checkpoint inhibitors. Our results support a clinical role of upfront cytoreductive nephrectomy in the modern era.

Real world treatment sequences and outcomes for metastatic renal cell carcinoma.

OBJECTIVES: The treatment landscape for metastatic renal cell carcinoma changed a lot in the last few years. This study aimed to assess the treatment sequences and outcomes for metastatic renal cell carcinoma in a real-world setting. MATERIALS AND METHODS: We enrolled patients with metastatic renal cell carcinomawho received first-line systemic treatment with tyrosin kinase inhibitors monotherapy, ipilimumab plus nivolumab, or pembrolizumab plus axitinibbetween January2009 and May 2023 on the database of TriNetX network. Overall survival, time on treatment and time to next treatment were evaluated using Kaplan-Meiermethod. RESULTS: Totally, 4183 received tyrosine kinase inhibitor monotherapy, 1555 received ipilimumab plus nivolumab, and 559 received axitinib plus pembrolizumab. Median time on treatment was 2.5 months for the tyrosine kinase inhibitor monotherapy cohort, 5.4 months for the ipilimumab plus nivolumab cohort, and 8.3 months for the pembrolizumab plus axitinib cohort. Median time to next treatment was 16.6 months for both the tyrosine kinase inhibitor monotherapy and ipilimumab plus nivolumab cohorts, and 22.1 months for the pembrolizumab plus axitinib cohort. Median overall survival was 42.2 months for the tyrosine kinase inhibitor monotherapy cohort, 39.7monthsfor the ipilimumab plus nivolumab cohort, and not reached for the pembrolizumab plus axitinib cohort. In comparison with the tyrosine kinase inhibitor monotherapy cohort, patients in the pembrolizumab plus axitinib cohort showed survival benefit (log-rank p = 0.0168) in overall survival, but not the case in the ipilimumab plus nivolumab cohort. CONCLUSION: There was a trend toward using first-line immuno-oncology based therapy for patients with metastatic renal cell carcinoma in a real-world practice. Axitinib plus pembrolizumuab cohort had survival benefits over tyrosine kinase inhibitor and ipilimumab plus nivolumab cohorts, while patients in the ipilimumab plus nivolumab cohort had more distant metastases and comorbidities.

Influence of Surgical Complications on Outcomes in Kidney Transplantation Patients.

BACKGROUND/AIM: With the increasing use of marginal donors, it is important to identify factors for outcomes in kidney transplantation. The aim of the present study was to evaluate the influence of surgical complications for graft survival after kidney transplantation and identify risk factors for surgical complications. PATIENTS AND METHODS: We performed a retrospective cohort study by chart review of patients who underwent kidney transplantation at the Taichung Veterans General Hospital in the period from 2007 to 2018. RESULTS: Of the 433 patients who underwent kidney transplantation, 57 experienced surgical complications with an occurrence rate of 13.2%. The most common complications were vascular complications (n=31; 7.2%), followed by urologic (n=9; 2%) and wound (n=9; 2%) complications. From univariate analyses, risk factors for surgical complications were cold ischemia time, blood loss, operation time, number of vascular anastomoses and year of operation. From univariate and multivariate analyses, operation time was associated to surgical complications. Patients with surgical complications experienced worse both one-year and five-year death-censored graft and patient survival. CONCLUSION: Surgical complications were associated with higher risk of death-censored graft failure and mortality. Cold ischemia time, blood loss, operation time, number of vascular anastomoses and year of operation were risk factors for surgical complications. Efforts should aim to minimize surgical complications to improve both graft and patient survival.

Tumor Size Significantly Affects Prognosis in Pathological T3a Renal Cell Carcinoma.

AIM: To evaluate the prognostic value of tumor size in patients with pathological T3aN0M0 renal cell carcinoma (RCC) postoperatively. PATIENTS AND METHODS: We retrospectively reviewed charts of patients with pathological T2N0M0 and T3aN0M0 RCC undergoing radical or partial nephrectomy at our Institution from 2000-2020. Survival analysis using Kaplan-Meier analysis and multivariate Cox regression was performed. RESULTS: A total of 165 patients were included and analyzed. We found that patients with pT3a RCC >7 cm experienced worse 5-year recurrence-free survival (43.8% versus 77.3%, p=0.006) and cancer-specific survival (67.6 versus 94%, p=0.003) compared with those with pT3a RCC ≤7 cm. However, there was no significant difference in recurrence-free and cancer-specific survival between patients with pT2 and pT3a RCC ≤7 cm. Based on multivariate analysis, tumor size >7 cm was an independent factor for tumor recurrence and cancer-related death [hazard ratio(HR)=2.654, p=0.005; and HR=5.016, p=0.005, respectively]. Renal vein invasion was associated with poorer 5-year recurrence-free survival than fat invasion (48.1% versus 70.9%, p=0.032) and was a predictor for tumor recurrence (HR=1.987, p=0.043). CONCLUSION: Tumor size has a significant impact on prognosis for patients with pathological T3aN0M0 RCC and should be taken into consideration when staging disease and predicting outcomes for these patients.

Prognostic Evaluation of the Site of Invasion in Pathological Stage T3a Renal Cell Carcinoma.

BACKGROUND/AIM: To investigate the prognostic values of fat invasion (FI) and renal vein invasion (RVI) in pT3a renal cell carcinoma (RCC), as single factors or concomitant presence. PATIENTS AND METHODS: We retrospectively reviewed the data of 173 patients who underwent radical or partial nephrectomy for RCC in our Institution. RESULTS: At a median follow-up time of 48 months, patients with RVI showed significantly increased risk of disease recurrence and worse cancer-specific survival (CSS) when compared to those with FI (p=0.007, p=0.022, respectively). Having combined RVI and FI did not show inferior prognosis compared to those with RVI only. In multivariable analysis, RVI was an independent factor for disease recurrence (HR=2.06, 95% CI=1.10-3.87, p=0.024) and CSS (HR=2.46, 95% CI=1.01-6.0, p=0.048). CONCLUSION: For patients with T3a renal tumors, RVI was associated with inferior prognosis compared to those with FI.

Association between lymphovascular invasion and oncological outcome in node-negative upper tract urothelial carcinoma with different stage.

OBJECTIVES: To evaluate the prognostic impact of lymphovascular invasion (LVI) on node-negative upper tract urothelial carcinoma (UTUC) in patients treated with radical nephroureterectomy (RNU). MATERIALS AND METHODS: A retrospective study was performed in single tertiary referral center of middle Taiwan between 2001 and 2015. Seven hundred and twenty-eight patients were diagnosed of UTUC and underwent RNU with ipsilateral bladder cuff excision including 303 and 195 patients with N0 and Nx status respectively. LVI status was assessed as a prognostic factor for cancer-specific (CSS) and overall survival (OS) using univariate and multivariate Cox regression analysis. RESULTS: LVI was observed in 82 patients (16.5%). LVI presentation associated with smoking status, advanced tumor stage, high tumor grade, positive surgical margin, and consequence lung/liver/bone metastasis. In the multivariate analysis, LVI was failed to predict CSS, OS, and disease-free survival (DFS) (hazard ratio [HR] [95% confidence interval [CI]: 1.07 [0.55-2.09], 1.05 [0.62-1.79], 1.15 [0.69-1.92], in CSS, OS, DFS, respectively). In the subgroup analysis of pT1-2 disease, the CSS, OS, and DFS were associated with LVI status (HR [95% CI]: 2.29 [0.44-11.84], 3.17 [1.16-8.67], 2.66 [1.04-6.79], in CSS, OS, DFS, respectively). In contrast, there was no difference in pT3 disease. CONCLUSION: In conclusion, LVI status was not associated with survival outcomes of node-negative UTUC in our study. The subgroup analysis showed different prognostic impacts of LVI status in node-negative UTUC with T1-2 and T3 stage. Further evidence to clarify the prognostic effect is needed to make LVI became a practical factor in clinical decision-making.

Survival Analysis of Pathological T3a Upstaging in Clinical T1 Renal Cell Carcinoma.

AIM: To evaluate the oncological outcomes of pathological T3a upstaging from clinical T1 renal cell carcinoma. PATIENTS AND METHODS: We retrospectively studied patients who underwent radical or partial nephrectomy for clinical T1 renal tumors. RESULTS: The median follow-up period was 44 months. At three and five years, the respective overall survival rate was 88.7% and 82.4% in pT3a disease, 95.7% and 93.4% in pT1 (p=0.008), the cancer-specific survival rate, 93.9% and 90.8% in pT3a, 99% and 97.7% in pT1 (p=0.001), and the recurrence-free survival rate, 79.7% and 71.0% in pT3a, and 95.5 and 94.3% in pT1 (p<0.001). CONCLUSION: Patients with pathological T3a upstaging tumors were associated with a significantly decreased survival rate, along with a higher recurrence rate when compared to those with pathological T1 disease.

Renal volume matters: Assessing the association between excisional volume loss and renal function after partial nephrectomy.

BACKGROUND/OBJECTIVES: To investigate the oncological and functional outcomes after partial nephrectomy for clinical stage T1 (cT1) renal cell carcinoma (RCC), and assess the association between excisional volume loss (EVL) and postoperative renal function. METHODS: We retrospectively reviewed 150 patients with cT1 RCC undergoing partial nephrectomy from 2002 to 2016. End-point evaluation was assessed by recurrence free survival (RFS), overall survival (OS), stage III and stage IV chronic kidney disease (CKD). Regression models were used to determine the risk factors of CKD after surgery. The relationship between EVL and renal function decline was evaluated using Spearman correlation method. RESULTS: Ninety patients with clinical stage T1a (cT1a) tumors and 60 patients with clinical stage T1b (cT1b) tumors were included. There were no differences in RFS, OS, and risk of stage III and stage IV CKD between the two groups. In Cox regression models, multivariate analysis showed that preoperative estimated glomerular filtration rate (eGFR) was an independent risk factor for developing stage III (hazard ratio 0.937, P < 0.001) and stage IV CKD (hazard ratio 0.929, P = 0.027). EVL was significantly associated with postoperative eGFR decrease. (Correlation Coefficient = 0.325, P = 0.003). CONCLUSIONS: Patients with cT1a and cT1b RCC have comparable oncological and functional outcome after partial nephrectomy, and preoperative eGFR is an independent factor to predict developing CKD. EVL has influence on the postoperative renal function decline.

Effect of HMGB1 Polymorphisms on Urothelial Cell Carcinoma Susceptibility and Clinicopathological Characteristics.

The high mobility group box 1 gene (HMGB1) plays a prominent role in cancer progression, angiogenesis, invasion, and metastasis. This study explored the effect of HMGB1 polymorphisms on clinicopathological characteristics of urothelial cell carcinoma (UCC). In total, 1293 participants (431 patients with UCC and 862 healthy controls) were recruited. Four single-nucleotide polymorphisms (SNPs) of HMGB1 (rs1412125, rs1360485, rs1045411, and rs2249825) were assessed using TaqMan real-time polymerase chain reaction assay. The results indicated that individuals carrying at least one T allele at rs1045411 had a lower risk of UCC than those with the wild-type allele [adjusted odds ratio = 0.722, 95% confidence interval (CI) = 0.565-0.924]. Furthermore, female patients with UCC carrying at least one T allele at rs1045411 were at a lower invasive tumor stage than those with the wild-type allele [odds ratio (OR) = 0.396, 95% CI = 0.169-0.929], similar to nonsmoking patients (OR = 0.607, 95% CI = 0.374-0.985). In conclusion, this is the first report on correlation between HMGB1 polymorphisms and UCC risk. Individuals carrying at least one T allele at rs1045411 are associated with a lower risk of UCC and a less invasive disease in women and nonsmokers.

Comparison of Efficacy of Adjuvant MEC (Methotrexate, Epirubicin and Cisplatin) and GC (Gemcitabine and Cisplatin) in Advanced Upper Tract Urothelial Carcinoma.

AIM: To evaluate the efficacy of methotrexate, epirubicin and cisplatin (MEC) or gemcitabine and cisplatin (GC) as adjuvant chemotherapy in advanced upper tract urothelium carcinoma (UTUC). PATIENTS AND METHODS: From 2002 January to 2008 December, a total of 70 patients with advanced UTUC received radical nephroureterctomy at our Institute with MEC and GC as adjuvant chemotherapy. Disease-free survival (DFS), cancer-specific survival (CSS) and overall survival (OS) among the two groups were evaluated. RESULTS: The MEC (n=30) and GC group (n=40) were compared and showed no significant differences in DFS (p=0.859), CSS (p=0.722) and OS (p=0.691). Positive lymph nodes, preoperative creatinine >1.5, old age, a high ECOG state and low BMI are all the independent risk factors of poor prognosis in advanced UTUC. CONCLUSION: In patients with UTUC, MEC has a non-inferior efficacy to GC in consideration of cancer recurrence, cancer-specific survival and overall survival.

Salvage Robotic-assisted Laparoscopic Radical Prostatectomy: Experience with 14 Cases.

AIM: To report the outcomes of salvage robot-assisted radical prostatectomy (S-RaRP). PATIENTS AND METHODS: Fourteen patients underwent S-RaRP. The mean initial prostatic-specific antigen level was 14.3 ng/ml and mean Gleason score was 6.93. Initial definitive treatment was external irradiation in 11 cases, cyberknife in two, and high-intensity focused ultrasound in one. Time from definitive treatment to S-RaRP was a mean of 36.5 months. RESULTS: The mean console time was 134.9 min and blood loss was 99.6 ml. Stage pT2N0, T3N0, and T3N1 were found in eight, four, and two cases, respectively. A positive surgical margin was found in 21.4% (3/14) of the patients. The continence rate was 71.4% (10/14). Mild stress urinary incontinence (one or two pads/day) was noted in 28.6% (4/14) of patients. Biochemical recurrence-free status was noted in 11 (78.5%) patients with a mean follow-up of 32.4 months. CONCLUSION: S-RaRP is feasible with a low complication rate, good continence rate, and an acceptable potency rate. The short-term oncological outcomes are encouraging.

Ureteroscopy-Assisted Laparoscopic Segmental Resection of Ureteral Stricture with a Modified Flank Position: Clinical Experience.

PURPOSE: To share the surgical technique that possesses the advantage of a perioperative ureteroscope without position change, which allows for a laparoscopic segmental resection of the ureteral stricture to be performed more precisely. PATIENTS AND METHODS: Between 2006 January and 2015 December, 10 patients with a ureteral stricture received a laparoscopic segmental resection and ureteroureterostomy in our clinical institute. The etiology included stone, endometriosis, crossing vessel, and idiopathic benign ureteral polyp. With the advance of bilateral lower extremities extended and abducted, 1 assistant used a ureteroscope as a direct guide to the precise location of the stricture affected ureter. Thus, the surgeon was able to perform a more specific resection without an unnecessary excision, which may have compromised the blood supply or increased the tension at anastomosis. RESULTS: Five patients received the traditional transperitoneal laparoscopic approach, whereas the other 5 patients received a ureteroscopy-assisted laparoscopic segmental resection and ureteroureterostomy. The operating time appears to be no different between the two groups (124 minutes versus 142 minutes, P = .351), and, thus, no additional time is consumed for the ureteroscope procedure. After at least 1 year of follow-up, only 1 patient in the traditional laparoscopic group suffered from recurrence. One patient had a right ureteral stricture due to stone impaction, where with the advantage of a ureteroscope guide without change position, the operator was able to make a limited excision at the affected location. No complications related to the decubitus and bilateral leg in the extended position were noted. CONCLUSIONS: Ureteroscopy-assisted laparoscopic segmental resection of the ureter without a change in position is a feasible and safe procedure when dealing with a refractory ureter stricture. Although it is convenient, the surgeon should be aware of possible pressure sores at the dependent part.

Prophylactic Robotic-assisted Laparoscopic Radical Prostatectomy for Preoperative Suspicion of Prostate Cancer: Experience with 55 Cases.

BACKGROUND/AIM: Expanded indications are not yet reported for robotic-assisted laparoscopic radical prostatectomy (RARP) performed by experienced surgeons for patients with preoperative suspicion of prostate cancer. We report our experience with 55 cases of prophylactic RARP for preoperative suspicion of prostate cancer, including postoperative pathological characteristics and outcomes. PATIENTS AND METHODS: This retrospective study reviewed data of a subset of 55 consecutive patients among 1,060 patients who underwent RARP for preoperative suspicion of prostate cancer. Pathological characteristics and outcomes of patients with suspected prostate cancer were analyzed and preoperative, intraoperative and postoperative parameters were compared between three groups. Patients were stratified by final pathology reports of RARP specimens: Group I: Prostate cancer, N=22 (40%); group II: abnormal (prostate intraepithelial neoplasia; atypical small acinar proliferation), N=18 (32.7%); and group III: benign (nodular hyperplasia or inflammation), N=15 (27.3%). RESULTS: Mean preoperative prostate-specific antigen (PSA) was 16.04±2.21 ng/ml. Twenty-two patients with adenocarcinoma had pathology stage pT2a/T2b/ T2c/T3a/T3b (6/7/2/6/1 patients, respectively), with positive surgical margins in 18.2% (4/22). Preoperative incidence of PSA velocity >0.75 ng/ml/yr was significantly higher in group I than in groups II and III (81.8% vs. 38.9% vs. 33.3%, p=0.004). Predictive parameters of prostate cancer showed that PSA velocity (>0.75 vs. ≤0.75 ng/ml/yr) had crude odds ratio of 9.0 for group I vs. group III, p=0.005. Posteperatively, statistically significant improvements were found in uroflow rate, post-voiding residual urine and symptom scores (all p<0.0001). CONCLUSION: Prophylactic RARP with bilateral neurovascular bundle preservation performed by experienced surgeons is a safe and viable option for preoperative suspicion of prostate cancer.

Prevention and Management of Complications During Robotic-assisted Laparoscopic Radical Prostatectomy Following Comprehensive Planning: A Large Series Involving a Single Surgeon.

AIM: To report a series of 1,000 patients treated by a single surgeon using robotic-assisted laparoscopic radical prostatectomy (RALP) and to show how to prevent and manage complications of the procedure. PATIENTS AND METHODS: Complication rates were prospectively assessed in a series of 1,000 consecutive patients who underwent RALP (group I, cases 1-200; IIa, 201-400; IIb, 401-600; IIIa, 601-800; and IIIb, 801-1000). Preoperative evaluation focused on patients' history of gout, use of drugs that can influence clotting time, and cardiopulmonary problems. Magnetic resonance imaging (MRI) was routinely performed. Operative difficulty was assessed based on the following variables: neoadjuvant hormonal therapy (NHT), obesity [body mass index (BMI) >30 kg/m(2)], prostate volume >70 g, presence of a large median lobe with intravesical protrusion >1 cm, previous transurethral resection of the prostate, previous pelvic surgery, previous extended pelvic lymph node dissection (EPLND), and salvage robotic radical prostatectomy (SRP). RESULTS: Operative difficulty tended to increase significantly with greater age, higher American Society of Anesthesiologists' anesthetic/surgical risk class scores, increased BMI, and more advanced clinical stage. The number of cases with NHT, obesity, previous pelvic surgery, EPLND, and SRP significantly increased from early to later groups of patients. Conversely, significantly less blood loss occurred in later groups of patients (group I, 179 ml to 97 ml in group IIIb; p<0.001). The need for blood transfusions gradually reduced from 3.5% to 0.5% in groups I and IIIb, respectively (p=0.022). The total complication rate was 6.4% (64/1,000; surgical/medical=5%/1.4%). Complication rates decreased significantly: 12%, 6%, 6%, 4%, and 4% in groups I, IIa, IIb, IIIa, and IIIb, respectively (p=0.003). The most common complications were blood transfusion and bowel problems (11/1,000=1.1%). CONCLUSION: Assessed in terms of groups of 200 cases, the surgeon's learning curve for RALP showed significantly fewer complications even as the operative difficulty of cases increased. The keys to preventing complications were meticulous preoperative evaluation of patients, MRI planning, and a dedicated robotic team for performing RALP. Early diagnosis and management of complications are paramount in patients who present any deviation from the normal postoperative course and clinical care pathway.

Pentafecta Outcomes of 230 Cases of Robotic-assisted Radical Prostatectomy with Bilateral Neurovascular Bundle Preservation.

AIM: We analyzed pentafecta outcomes [complication-free, continence, potency, negative surgical margins (NSM)], biochemical recurrence (BCR)-free] of 230 patients undergoing robotic-assisted radical prostatectomy (RARP) with bilateral neurovascular (NVB) preservation. PATIENTS AND METHODS: Patient outcomes (group I, cases 1-115; group II, cases 116-230) were assessed prospectively. Definitions were: continence, using no pads; potency, ability to achieve/maintain erections firm enough for sexual intercourse; positive surgical margin, presence of tumor tissue on inked specimen surface; and BCR, two consecutive PSA levels >0.2 ng/ml after RALP. RESULTS: The mean patient age was 62.5 years, mean PSA=8.62 ng/ml. The complication-free rate was 93.9% (216/230), continence rate 98.3% (226/230), potency 86.1% (198/230), NSM 77.0% (177/230) and BCR-free 92.6% (213/230). The trifecta rate (continence, potency, BCR-free) was 81.7% (188/230). The pentafecta rate was 60.4% (139/230). CONCLUSION: Pentafecta is the new standard of outcomes for RARP with bilateral NVB, with patient selection and reduced positive surgical margins attaining best outcomes.

The surgical learning curve for robotic-assisted laparoscopic radical prostatectomy: experience of a single surgeon with 500 cases in Taiwan, China.

To analyze the learning curve for cancer control from an initial 250 cases (Group I) and subsequent 250 cases (Group II) of robotic-assisted laparoscopic radical prostatectomy (RALP) performed by a single surgeon. Five hundred consecutive patients with clinically localized prostate cancer received RALP and were evaluated. Surgical parameters and perioperative complications were compared between the groups. Positive surgical margin (PSM) and biochemical recurrence (BCR) were assessed as cancer control outcomes. Patients in Group II had significantly more advanced prostate cancer than those in Group I (22.2% vs 14.2%, respectively, with Gleason score 8-10, P= 0.033; 12.8% vs 5.6%, respectively, with clinical stage T3, P= 0.017). The incidence of PSM in pT3 was decreased significantly from 49% in Group I to 32.6% in Group II. A meaningful trend was noted for a decreasing PSM rate with each consecutive group of 50 cases, including pT3 and high-risk patients. Neurovascular bundle (NVB) preservation was significantly influenced by the PSM in high-risk patients (84.1% in the preservation group vs 43.9% in the nonpreservation group). The 3-year, 5-year, and 7-year BCR-free survival rates were 79.2%, 75.3%, and 70.2%, respectively. In conclusion, the incidence of PSM in pT3 was decreased significantly after 250 cases. There was a trend in the surgical learning curve for decreasing PSM with each group of 50 cases. NVB preservation during RALP for the high-risk group is not suggested due to increasing PSM.

Retro-apical transection of the urethra during robot-assisted laparoscopic radical prostatectomy in an Asian population.

UNLABELLED: Retro-apical transection of urethra during RARP in an Asian population was found to be feasible. A dedicated team, using robot-assisted surgery, with a skillful assistant are required for the procedure to become standard practice. We would recommend the retro-apical approach for all patients receiving RARP, as it was not found to increase surgical risk or complication. The continence rate at 3 months and 6 months were similar between two groups (70% and 95% in retro-apical group vs 60% and 90% in anterior-apical group). OBJECTIVE: To assess the feasibility of retro-apical transection of the urethra during robot-assisted radical prostatectomy (RARP) in an Asian population. PATIENTS AND METHODS: Eighty consecutive patients with clinically localized prostate cancer underwent RARP performed by a single surgeon. Patients who underwent retro-apical or anterior-apical urethral transection during RARP were allocated to Group 1 or Group 2, respectively. Preoperative clinical characteristics were recorded, pelvic bone measurements taken and prostatic apex shape was assessed using magnetic resonance imaging. Operating characteristics were compared between the groups and pathological outcomes were assessed. RESULTS: Of the 80 patients, 75% were in Group 1 and 25% in Group 2. Pelvic bone size and apex shape were similar between the two groups. Group 2 had a significantly higher mean (sd) preoperative body mass index (BMI) than Group 1 (27.43 [4.15] vs 23.50 [2.71] kg/m(2); P < 0.001) and significantly higher prostate weight than Group 1 (52.00 [31.89] vs 36.55 [11.57] g; P < 0.05). More of those in Group 2 than in Group 1 had undergone previous transurethral resection of the prostate ([TURP] 25% vs 1.67%; P = 0.003) and the mean tumour volume in Group 2 was significantly higher than in Group 1 (15.17 vs 8.10 mL; P = 0.049). The incidence of retro-apical transection of the urethra was 62.5% and 82.5% in the initial 40 cases and subsequent 40 cases, respectively (P = 0.02). CONCLUSION: High BMI, larger prostate volume and previous TURP, but not pelvic bone size or apex shape, might hinder retro-apical transection of the urethra.

Simultaneous robot-assisted nephroureterectomy and cystectomy in patients with uremia and multifocal urothelial carcinoma.

BACKGROUND AND PURPOSE: In Taiwan, patients with uremia have a high risk of the development of multifocal urothelial carcinoma. We report on eight patients with uremia and urothelial carcinoma who underwent simultaneous robot-assisted laparoscopic nephroureterectomy and radical cystectomy (RANUC). PATIENTS AND METHODS: Between April 2006 and August 2010, eight patients with uremia (five women, three men; mean age 66.9 y) who were receiving dialysis underwent RANUC. Patients were classified into two groups: Group I, cases 1 to 4 occurring between April 2006 and June 2009; and group II, cases 5 to 8 occurring between July 2009 and August 2010. RESULTS: The mean operative time was significantly shorter in group II (252.5±35.0 min vs 360±25.8 min; P=0.029). The estimated blood loss was also significantly less in group II (332.5±53.8 mL vs 660±137.4 mL; P=0.029). The blood transfusion rate was 75% in group I and 0% in group II. The postoperative stay was reduced from 8.5 days for group I to 7 days for group II. No perioperative morbidity and mortality were noted in either group. None of the patients had died at the short- and intermediate-term mean follow-up of 28.1 months (range 2-54 mos). CONCLUSIONS: Simultaneous RANUC are feasible and can be performed safely. Long-term oncologic data are awaited; however, at intermediate-term oncologic follow-up, results are satisfactory. RANUC for uremic patients with multifocal urothelial carcinoma necessitating complete urinary tract exenteration is a viable option and patients experience a rapid convalescence.

The learning curve for reducing complications of robotic-assisted laparoscopic radical prostatectomy by a single surgeon.

UNLABELLED: OBJECTIVE • To analyse the learning curve for reducing complications of robotic-assisted laparoscopic radical prostatectomy (RALP) performed by a single surgeon in Taiwan. PATIENTS AND METHODS: • Complication rates were prospectively assessed in 200 consecutive patients undergoing RALP (Group I: cases 1-50; Group II: cases 51-100; Group III: cases 101-150 and Group IV: cases 151-200). • Complications were classified using the Clavien system: grade I: deviation normal postoperative course without treatment; grade II: drug or bedside treatment; grade III: endoscopic or surgical intervention; grade IV: life-threatening problem; and grade V: death. • Operative parameters and peri-operative complications were evaluated, including operative and console time, blood loss and transfusion rate, Gleason scores, positive surgical margin (PSM) rate, specimen volume, tumour size, tumour percentage, node positive rate and intra- and postoperative complications. RESULTS: • RALP console time was gradually lowered from Group I to Group IV (P < 0.05). Significantly less blood loss occurred after every 50 cases of RALP (Group I 275 mL, Group II 179 mL, Group III 145 mL, Group IV 102 mL, P < 0.001). • Blood transfusion incidence was 8%, 4%, 2% and 0% in Groups I, II, III and IV, respectively. • Complication rates were 18%, 12%, 18% and 0% in Groups I, II, III and IV, respectively. • Major complications (grade III-IV) were 6%, 2%, 4% and 0% in Groups I, II, III and IV, respectively. • Bowel injury occurred in three cases (Group II: 1; Group III: 2); one received intra-operative repair without sequelae and two received a transient colostomy and later colostomy closure. CONCLUSIONS: • The learning curve for every 50 cases of RALP showed significantly less blood loss and blood transfusion rate. • The learning curve for significantly decreasing complications is 150 cases.