Prostate Cancer Risk Stratification by Simple Scoring of the Current pT3 Lesions: A Proposal for a New Pathologic T-Staging System.

Cancer spread beyond the prostate, including extraprostatic extension (other than seminal vesicle or bladder invasion; EPE)/microscopic bladder neck invasion and seminal vesicle invasion (SVI) currently classified as pT3a and pT3b lesions, respectively, does not uniformly indicate poor oncologic outcomes. Accurate risk stratification of current pT3 disease is therefore required. We herein further determined the prognostic impact of these histopathologic lesions routinely assessed and reported by pathologists, particularly their combinations. We assessed consecutive 2892 patients undergoing radical prostatectomy for current pT2 (n = 1692), pT3a (n = 956), or pT3b (n = 244) disease at our institution between 2009 and 2018. Based on our preliminary findings, point(s) were given (1 point to focal EPE, microscopic bladder neck invasion, or unilateral SVI; 2 points to nonfocal/established EPE or bilateral SVI) and summed up in each case. Our cohort had 0 point (n = 1692, 58.5%; P0), 1 point (n = 243, 8.4%; P1), 2 points (n = 657, 22.7%; P2), 3 points (n = 192, 6.6%; P3), 4 points (n = 76, 2.6%; P4), and 5 points (n = 32, 1.1%; P5). Univariate analysis revealed associations of higher points with significantly worse biochemical progression-free survival, particularly when P4 and P5 were combined. In multivariable analysis (P0 as a reference), P1 (hazard ratio [HR], 1.57; P = .033), P2 (HR, 3.25; P < .001), P3 (HR, 4.01; P < .001), and P4 + P5 (HR, 5.99; P < .001) showed significance for the risk of postoperative progression. Meanwhile, Harrell C-indexes for the current pT staging, newly developed point system, and the Cancer of the Prostate Risk Assessment post-Surgical (CAPRA-S) score were 0.727 (95% CI, 0.706-0.748), 0.751 (95% CI, 0.729-0.773), and 0.774 (95% CI, 0.755-0.794), respectively, for predicting progression. We believe our data provide a logical rationale for a novel pathologic T-staging system based on the summed points, pT1a (0 point), pT1b (1 point), pT2 (2 points), pT3a (3 points), and pT3b (4 or 5 points), which more accurately stratifies the prognosis of prostate cancer.

Standard Multiport vs Single-Port Robot-Assisted Simple Prostatectomy: A Single-Center Initial Experience.

Background: Robot-assisted simple prostatectomy (RASP) has emerged as a safe surgical treatment for patients with benign prostatic hyperplasia with large glands (>80 mL). Several studies reported on perioperative outcomes of RASP by the standard multiport (MP) da Vinci® robotic system approach. Studies conducted on RASP utilizing the novel single-port (SP) da Vinci SP robotic platform (Intuitive Surgical, Sunnyvale, CA) are scarce. We aimed to compare intraoperative and short-term postoperative outcomes between the da Vinci MP and SP robots for patients undergoing RASP in a referral center. Methods: In this retrospective study, we reviewed all patients who underwent RASP using MP or SP robot from September 2016 to March 2021. Intraoperative data, overall 30-day complications, complications by Clavien-Dindo classification, and 90-day readmission and reoperation rates were assessed and compared between the two groups using appropriate statistical methods. Results: Seventy-five patients who underwent RASP were identified. Of these, 47 were in the MP group and 28 were in the SP. Compared with SP, mean operative time in MP group was 216.6 vs 232.4 minutes (p = 0.39), estimated blood loss was 195.7 vs 227.1 mL (p = 0.43), and length of stay was 2 vs 2.5 days (p = 0.45). There was a trend toward higher overall complication rate in SP group vs MP (42.86% vs 21.28%, p = 0.09). There were no significant differences in the readmission (17.02% vs 10.71%, p = 0.52) and reoperation (2.1% vs 7.14%, p = 0.34) rates between MP vs SP group. Conclusion: SP-RASP is safe and shows equivalent perioperative outcomes when compared with the MP robotic system. A marginal increase of complication rate was recorded in the SP group; however, this did not demonstrate statistical significance.

Design and Implementation of an Emergency Undocking Curriculum for Robotic Surgery.

INTRODUCTION: Current training for robotic surgery crisis management, specifically emergency robotic undocking protocol (ERUP), remains limited to anecdotal experience. A curriculum to impart the skills and knowledge necessary to recognize and complete a successful ERUP was developed using an education approach then evaluated. METHODS: Baseline knowledge and confidence regarding ERUP were established for 5 robotic teams before completing 2 full-immersion simulations separated by an online self-paced learning module. In each simulation, teams operated on a perfused hydrogel model and were tasked to dissect a retroperitoneal tumor abutting a major vessel. During vascular pedicle ligation, a major vascular bleed and nonrecoverable robotic fault were remotely induced, necessitating ERUP with open conversion. After the simulation, participants completed surgery task load index (cognitive load assessment) and realism surveys. Weighted checklists scored participants' actions during each simulation. Surgical metrics including estimated blood loss, time to control bleeding, and undocking time were recorded. Curriculum retention was assessed by repeating the exercise at 6 months. RESULTS: Participants experienced high levels of cognitive demand and agreed that the simulation's realism and stress mimicked live surgery. Longitudinal analysis showed significant knowledge (+37.5 points, p = 0.004) and confidence (+15.3 points, p < 0.001) improvements from baseline to completion. Between simulations, checklist errors, undocking time, and estimated blood loss decreased (38⇾17, -40 seconds, and -500 mL, respectively), whereas action scores increased significantly (+27 points, p = 0.008). At 6 months, insignificant changes from curriculum completion were seen in knowledge (-4.8 points, p = 0.36) and confidence (+3.7 points, p = 0.1). CONCLUSIONS: This simulation-based curriculum successfully improves operative team's confidence, knowledge, and skills required to manage robotic crisis events.

Extraperitoneal Single-Port Robot-Assisted Radical Prostatectomy.

Robot-assisted radical prostatectomy (RARP) is currently the standard minimally invasive procedure for the surgical management of localized prostate cancer. It has been shown that the minimally invasive robotic approach offers comparable oncologic and functional outcomes with potential advantages, including decreased blood loss, shorter hospital stay, and recovery period when compared with open surgery. Generally, the transperitoneal RARP approach is the most commonly performed among robotic surgeons, owing to its wider space and early adoption. However, similar oncologic outcomes have been reported with the extraperitoneal approach. Owing to its perceived technical difficulty, extraperitoneal RARP is less adopted nowadays. This approach, however, has its merits particularly in cases where intraperitoneal access can be problematic with extensive adhesions from previous surgeries. Also, extraperitoneal approach allows for minimal bowel manipulation, less steep Trendelenburg positioning, and less pneumoperitoneum, which reflect on early recovery of bowel function after RARP. Both transperitoneal and extraperitoneal approaches can be performed using either the conventional multiport robotic system or the more recent single-port (SP) robotic system. With respect to extraperitoneal RARP, there has been an increased adoption of the SP system, with purported advantages such as better cosmesis, less postoperative analgesic and opioid requirements, and shorter duration of hospital stay. Herein, we describe the technical steps relevant to extraperitoneal single-port robot-assisted radical prostatectomy, and elaborate on the clinical outcomes reported in the literature.

Application of IRIS Three-Dimensional Anatomical Models As Preoperative Surgical Planning Tools in the Management of Localized Renal Masses.

Introduction: The use of volume-rendered images is gaining popularity in the surgical planning for complex procedures. IRIS™ is an interactive software that delivers three-dimensional (3D) virtual anatomical models. We aimed to evaluate the preoperative clinical utility of IRIS for patients with ≤T2 localized renal tumors who underwent either partial nephrectomy (PN) or radical nephrectomy (RN). Patients and Methods: Six urologists (four faculty and two trainees) reviewed CT scans of 40 cases over 2 study phases, using conventional two-dimensional (2D) CT alone (Phase-I), followed by the CT + IRIS 3D model (Phase-II). After each review, surgeons reported their decision on performing a PN or an RN and rated (Likert scale) their confidence in completing the procedure as well as how the imaging modality influenced specific procedural decisions. Modifications to the choice of procedure and confidence in decisions between both phases were compared for the same surgeon. Concordance between surgeons was also evaluated. Results: A total of 462 reviews were included in the analysis (231 in each phase). In 64% (95% CI: 58-70%) of reviews, surgeons reported that IRIS achieved a better spatial orientation, understanding of the anatomy, and offered additional information compared with 2D CT alone. IRIS impacted the planned procedure in 20% of the reviews (3.5% changed decision from PN to RN and 16.5% changed from RN to PN). In the remaining 80% of reviews, surgeons' confidence increased from 78% (95% CI: 72-84%) with 2D CT, to 87% (95% CI: 82-92%) with IRIS (p = 0.02); this confidence change was more pronounced in cases with a high RENAL score (p = 0.009). In 99% of the reviews, surgeons rated that the IRIS accurately represented the anatomical details of all kidney components. Conclusion: Application of IRIS 3D models could influence the surgical decision-making process and improve surgeons' confidence, especially for robot-assisted management of complex renal tumors.

Robot-assisted Synchronous Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease: A Stepwise Description of Technique.

OBJECTIVE: To describe our technique of robot-assisted synchronous bilateral nephrectomy (RASBN) for autosomal dominant polycystic kidney disease (ADPKD). METHODS: Given prior abdominal surgery/transplant in most patients, we prefer an open cut-down access to place a 12 mm port 10 cm infraumbilically. Four (8 mm) robotic ports are then placed under vision in a fan distribution along the umbilical level. The operating table is placed in reverse Trendelenburg and tilted opposite to the targeted side. Provided there are no concerns for malignancy, some cysts encountered in large kidneys (>2.5 L) may require puncture, to facilitate access and mobilization. The resected kidney is placed in a large bag and tucked in the pelvis. A similar procedure is carried out on the contralateral side after redocking the robot and tilting the table in the opposite direction. The specimen bags are extracted by elongating the lower midline 12 mm port site. RESULTS: Seven cases of RASBN performed for ADPKD were identified (December 2015 to December 2018). Median (interquartile range, IQR) values for patient demographics were: Age = 59 years (47-63), body mass index = 29 (26-32), and American Society of Anaesthesiology grade = 3. Three patients had prior deceased- and 4 had prior living- donor transplants. Indication for nephrectomy were: pain (5), hemorrhage into cysts (3), and renal masses (2). Perioperative outcomes were: operating room time = 388 minutes, estimated blood loss = 200 mL, hemoglobin change = 1.3 g/dL, transfusion = 0, length of hospital stay = 3 days, Grade I Clavien-Dindo complications = 2 cases. All patients were alive at a median follow-up of 3.8 years. CONCLUSION: RASBN is safe and effective in ADPKD even in the context of prior renal transplant patients with attendant comorbidities.

Oncological and functional outcomes in patients over 70 years of age treated with robotic radical prostatectomy: a propensity-matched analysis.

PURPOSE: The aim of this study was to report on the safety (complications) and efficacy (oncological and functional outcomes) of robot-assisted radical prostatectomy (RARP), performed at our institution, in patients aged over 70. PATIENTS AND METHODS: Review of our prospectively collected database [Cancer Information Systems (CAISIS)] identified two hundred and fifteen (215) patients, aged > 70, who underwent RARP for localized prostate cancer between July 2003 and August 2017. A propensity score-matched analysis, with multiple covariates, was performed to stratify the patients into Age ≤ 70 and Age > 70 comparison groups. RESULTS: Apart from Age (mean ± SD years: 73.5 ± 2.1 vs 59.5 ± 5.9, p < 0.0001) and nerve-sparing status, the two groups were evenly matched for all covariates (p values > 0.05). Median follow-up was 10.6 years. There were no 90-day mortalities in either group. Minor complications (Clavien ≤ 2) were more common in the Age > 70 group (p = 0.0002). Operating room time (p = 0.83), length of hospital stay (p = 0.06) and catheterization duration (p = 0.13) were similar. On final pathology, a higher pT stage (p < 0.0001) and pN1 (p = 0.003) were observed in the Age > 70 group. However, this did not translate adversely into higher rates of positive surgical margin (p = 0.41) or biochemical relapse (p = 0.72). Allowing for the follow-up duration (median 10.6 years), cancer-specific survival was marginally significant (p = 0.05) with an observed lower rate in the Age > 70 group. In terms of functional outcomes, post-operative erectile dysfunction and pad-free continence were significantly better in the younger cohort (p < 0.0001). CONCLUSIONS: Robot-assisted radical prostatectomy should not be denied to those over 70 years solely on the basis of age. Older men need to be counseled about the likelihood of encountering higher-risk features on final pathology and that their functional outcomes may be worse compared to a younger person.

Transvesical Versus Transabdominal - Which is the Best Approach to Bladder Diverticulectomy Using the Single Port Robotic System?

OBJECTIVE: Application of the Single Port (SP) robotic platform [Intuitive] is expanding. Using 2 illustrative examples of bladder diverticula (BD) resulting from bladder outflow obstruction (BOO), we describe in this video our techniques utilizing SP to treat BD via Extravesical (EV#1) and Transvesical (TV#2) approaches. METHODS: In EV#1, a 56-year old, with BOO due to benign prostate enlargement (BPE) of a 30 mL prostate, and a 5 cm BD, was treated with RABD-SP. A subumbilical SP access was used to approach and excise the BD in an EV fashion. The BPE was treated with Rezum. A 16 Fr urethral catheter was placed. In TV#2, a 67-year old, with urinary retention due to a 55 mL BPE and a 6 cm BD in the right posterolateral aspect adjacent the ureteric orifice, was treated with RABD-SP using a Gelport (no additional assistant ports). An open cut-down was performed onto a prefilled bladder and secured onto the abdominal wall with stay sutures. After draining the bladder, a Gelport was introduced into the bladder for SP docking with pneumo-vesical insufflation. Intravesical (inside-out) excision of the BD was performed with protection of the adjacent right ureteric orifice with an open access ureteral catheter. Utilizing the TV access, a simple prostatectomy was performed. A 22 Fr, 3-way catheter was placed at the end. RESULTS: For EV#1 and TV#2, estimated blood losses were 5 and 100 mL, length stay was 1 day in both, without any immediate perioperative complications. Both patients had successful trials of void on postoperative day 7 and 9, respectively. CONCLUSION: RABD-SP can be customized to treat BD, via transabdominal (extravesical) or transvesical (with bladder pneumo-insufflation) approaches, and combined with different BOO treatments (Rezum or simple prostatectomy, for instance), in a patient-specific personalized manner.

Accelerated Skills Acquisition Protocol (ASAP) in optimizing robotic surgical simulation training: a prospective randomized study.

PURPOSE: To assess the efficacy of an accelerated proficiency-based training protocol in robotic simulation practice in delivering durable proficiency compared to conventional training methods. METHODS: Novice medical students (n = 16) were randomized into either the accelerated skills acquisition protocol (ASAP) or conventional training protocol (CTP). Subjects were trained to proficiency on the da Vinci Skills Simulator (dVSS) by an expert trainer. Differences in the repetitions required to achieve proficiency in two simple and two complex virtual reality (VR) training tasks were assessed as the primary outcome measure. Transfer of the acquired skills to two other non-practiced tasks was assessed immediately and prospectively followed through to 3, 6 and 12 months in the two groups. Retention of the practiced tasks was assessed along the same timeframe. RESULTS: Subjects in the ASAP group acquired proficiency significantly faster in three of the four training tasks: camera control (p = 0.0002), suture sponge (p < 0.0001), ring walk3 (p < 0.0001), and peg board (p = 0.6936). When assessing transfer of skills, there were no significant differences between the two groups: Ring rail 3 (p = 0.6807) and Tubes (p = 0.2240). When assessing retention of skills at 3, 6 and 12 months, for all 6 tasks, no significant differences were seen between the ASAP and CTP groups. CONCLUSION: ASAP is proven to be an efficient approach for delivering proficiency in robotic VR simulation training. The results are durable when compared to conventional simulation training methods. The findings may have significant implications in the design of robotic VR simulation curricula.

Incorporation and validation of clinically relevant performance metrics of simulation (CRPMS) into a novel full-immersion simulation platform for nerve-sparing robot-assisted radical prostatectomy (NS-RARP) utilizing three-dimensional printing and hydrogel casting technology.

OBJECTIVES: To incorporate and validate clinically relevant performance metrics of simulation (CRPMS) into a hydrogel model for nerve-sparing robot-assisted radical prostatectomy (NS-RARP). MATERIALS AND METHODS: Anatomically accurate models of the human pelvis, bladder, prostate, urethra, neurovascular bundle (NVB) and relevant adjacent structures were created from patient MRI by injecting polyvinyl alcohol (PVA) hydrogels into three-dimensionally printed injection molds. The following steps of NS-RARP were simulated: bladder neck dissection; seminal vesicle mobilization; NVB dissection; and urethrovesical anastomosis (UVA). Five experts (caseload >500) and nine novices (caseload <50) completed the simulation. Force applied to the NVB during the dissection was quantified by a novel tension wire sensor system fabricated into the NVB. Post-simulation margin status (assessed by induction of chemiluminescent reaction with fluorescent dye mixed into the prostate PVA) and UVA weathertightness (via a standard 180-mL leak test) were also assessed. Objective scoring, using Global Evaluative Assessment of Robotic Skills (GEARS) and Robotic Anastomosis Competency Evaluation (RACE), was performed by two blinded surgeons. GEARS scores were correlated with forces applied to the NVB, and RACE scores were correlated with UVA leak rates. RESULTS: The expert group achieved faster task-specific times for nerve-sparing (P = 0.007) and superior surgical margin results (P = 0.011). Nerve forces applied were significantly lower for the expert group with regard to maximum force (P = 0.011), average force (P = 0.011), peak frequency (P = 0.027) and total energy (P = 0.003). Higher force sensitivity (subcategory of GEARS score) and total GEARS score correlated with lower nerve forces (total energy in Joules) applied to NVB during the simulation with a correlation coefficient (r value) of -0.66 (P = 0.019) and -0.87 (P = 0.000), respectively. Both total and force sensitivity GEARS scores were significantly higher in the expert group compared to the novice group (P = 0.003). UVA leak rate highly correlated with total RACE score r value = -0.86 (P = 0.000). Mean RACE scores were also significantly different between novices and experts (P = 0.003). CONCLUSION: We present a realistic, feedback-driven, full-immersion simulation platform for the development and evaluation of surgical skills pertinent to NS-RARP. The correlation of validated objective metrics (GEARS and RACE) with our CRPMS suggests their application as a novel method for real-time assessment and feedback during robotic surgery training. Further work is required to assess the ability to predict live surgical outcomes.

Multi-institutional Clinical Tool for Predicting High-risk Lesions on 3Tesla Multiparametric Prostate Magnetic Resonance Imaging.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) for prostate cancer detection without careful patient selection may lead to excessive resource utilization and costs. OBJECTIVE: To develop and validate a clinical tool for predicting the presence of high-risk lesions on mpMRI. DESIGN, SETTING, AND PARTICIPANTS: Four tertiary care centers were included in this retrospective and prospective study (BiRCH Study Collaborative). Statistical models were generated using 1269 biopsy-naive, prior negative biopsy, and active surveillance patients who underwent mpMRI. Using age, prostate-specific antigen, and prostate volume, a support vector machine model was developed for predicting the probability of harboring Prostate Imaging Reporting and Data System 4 or 5 lesions. The accuracy of future predictions was then prospectively assessed in 214 consecutive patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Receiver operating characteristic, calibration, and decision curves were generated to assess model performance. RESULTS AND LIMITATIONS: For biopsy-naïve and prior negative biopsy patients (n=811), the area under the curve (AUC) was 0.730 on internal validation. Excellent calibration and high net clinical benefit were observed. On prospective external validation at two separate institutions (n=88 and n=126), the machine learning model discriminated with AUCs of 0.740 and 0.744, respectively. The final model was developed on the Microsoft Azure Machine Learning platform (birch.azurewebsites.net). This model requires a prostate volume measurement as input. CONCLUSIONS: In patients who are naïve to biopsy or those with a prior negative biopsy, BiRCH models can be used to select patients for mpMRI. PATIENT SUMMARY: In this multicenter study, we developed and prospectively validated a calculator that can be used to predict prostate magnetic resonance imaging (MRI) results using patient age, prostate-specific antigen, and prostate volume as input. This tool can aid health care professionals and patients to make an informed decision regarding whether to get an MRI.

Robot-Assisted Simple Prostatectomy: Illustration of a Simplified Extraperitoneal Transcapsular Technique.

Introduction and Objectives: Robot-assisted simple prostatectomy (RASP) performed with the extraperitoneal (EP) technique (RASP-EP) minimizes the risk of bowel injury, particularly when bowel adhesions may be expected to be prominent, by negating the need to be in the transperitoneal space. However, there is a perception of its technical difficulty owing to the limited space that can be expanded within the space of Retzius. We aimed to describe, in the accompanying video, the step-by-step approach for a technically proficient procedure. Methods: From January 2010 to July 2018, 33 consecutive patients who had undergone RASP-EP were identified from our institutional database. Procedures were performed as described stepwise in the accompanying video. In RASP-EP, a 3 cm paraumbilical incision is made, anterior rectus sheath incised, muscle pushed laterally, and the EP space is entered. The EP space is expanded in the retropubic area using a balloon dilator and a blunt ended trocar, enabling the placement of further three ports for robot docking. A transverse capsulotomy, 2 cm from the bladder neck, is performed a la Millin's. Prostate adenoma is resected circumferentially. Electrocautery hemostasis is performed. Posterior bladder neck and urethra are sutured onto the prostatic fossa with 2-0 Vicryl. A 22F three-way catheter is placed. Anterior capsulotomy is closed in two layers with 2-0 and 0-0 Vicryl sutures. A drain is left in the retropubic space. Patient is discharged within 1-2 days with the catheter in situ, which is then removed 10 days later. Results: Of the 33 patients, median values were age (68), American Society of Anesthesiology (3), Charlson Comorbidity Index (3), and body mass index (28.5 kg/m2). Eight (24.2%) patients had prior abdominal surgeries. Twenty-five (75.8%) patients were catheter dependent. Adjunctive procedures were cystolithotomy (5), umbilical hernia repair (2), and ureteroscopy (1). Median values were operative time (178 minutes), estimated blood loss (200 mL), hemoglobin change (2.8 g/dL), and hematocrit change (9%); only one patient (3.0%) required 1 U transfusion. Median length of stay was 2 days. Clavien-Dindo complications were 0 (21), I (7), II (3), IIIa (1), IIIb (1), IV, and V (0). Median resected prostate weight was 122 g. Incidental prostate cancer was found in three patients (9%); one patient required adjuvant radiotherapy. No patients were catheter-dependent postoperatively; mean postvoid residual was 29 mL (range 0-250 mL). Median follow-up was 4 months. Conclusions: RASP-EP is a safe and efficacious technique that should form the repertoire of a urologist's armamentarium when dealing with large adenomas, particularly when entry into the peritoneal cavity is to be avoided. No competing financial interests exist. Runtime of video: 7 mins 5 secs.

Antibiotic prophylaxis at the time of catheter removal after radical prostatectomy: A prospective randomized clinical trial.

OBJECTIVE: To evaluate the role of antibiotic prophylaxis with oral ciprofloxacin prior to urinary catheter removal after radical prostatectomy in preventing urinary tract infection (UTI). MATERIALS AND METHODS: Patients undergoing radical prostatectomy were prospectively enrolled and randomized to either the antibiotic prophylaxis group (2 doses of oral ciprofloxacin prior to urinary catheter removal) or the control group (no antibiotics given prior to urinary catheter removal). Neither patients nor study providers were blinded to the group. The primary objective was to assess for development of UTI. The secondary objective was to assess for development of Clostridium difficile (C diff) enterocolitis. Continuous variables were compared using a 2-sample t test. Categorical variables were compared using Pearson's chi-squared test or Fisher's exact test. RESULTS: One hundred seventy-five patients were enrolled and randomized (90 control and 85 antibiotic prophylaxis). After randomization, 4 patients were excluded and 4 patients withdrew voluntarily. One hundred sixty-seven patients (84 control and 83 antibiotic prophylaxis) completed the study and were available for analysis. There were no significant differences in baseline characteristics, perioperative data, or complications. There was no significant difference in the rate of UTI between the control group and antibiotic prophylaxis group (5.95% vs. 6.02%, P = 1). There was also no significant difference in the rates of C diff infection between the control and the antibiotic prophylaxis groups (3.57% vs. 0%, P = 0.21). CONCLUSIONS: In this prospective, randomized, controlled trial, the use of antibiotic prophylaxis with oral ciprofloxacin prior to urinary catheter removal after radical prostatectomy did not decrease the rate of UTI, and was not associated with an increased incidence of C diff enterocolitis.

The role of urinary cytology when diagnostic workup is suspicious for upper tract urothelial carcinoma but tumour biopsy is nonconfirmatory.

INTRODUCTION: We sought to determine the value of obtaining preoperative urinary cytology when diagnostic workup of an upper tract mass is suspicious for upper tract urothelial carcinoma (UTUC), but biopsy fails to confirm the diagnosis. METHODS: Using billing code data, 239 patients were identified as having undergone radical nephroureterectomy (RNU) by 16 urologists from September 29, 1998 to July 31, 2015. Of this group, 19 adult patients had a presumed preoperative diagnosis of UTUC in a native kidney, at least three months of followup, no history of concurrent radical cystectomy with RNU, and negative/non-diagnostic tissue biopsy. These patients were divided into three groups: Group A had no urinary cytology taken (n=6); Group B had upper and/or lower tract cytology performed with neither positive nor atypical (n=7); Group C had upper and/or lower tract cytology performed with at least one positive or atypical (n=6). RESULTS: Demographic information and diagnostic workup was similar between the groups, although Group A had more patients with a history of prior radical cystectomy for bladder cancer (p=0.02). One patient in Group B had benign tissue on final pathology. All patients in Groups A and C had malignancy on final pathology and overall, the three groups had similar rates of malignancy. CONCLUSIONS: When a composite of clinical findings suggest UTUC, performing urinary cytology may not be necessary. A negative result in this setting should not be used to rule out UTUC, as this is often discordant with final pathology. A positive cytology result may help solidify the diagnosis when other findings are less clear.

Rate of Symptomatic Lymphocele Formation After Extraperitoneal vs Transperitoneal Robot-Assisted Radical Prostatectomy and Bilateral Pelvic Lymphadenectomy.

INTRODUCTION AND OBJECTIVE: With the peritoneum acting as a natural surface for lymphatic reabsorption, transperitoneal robot-assisted radical prostatectomy (tRARP) is thought to be associated with a lower incidence of symptomatic lymphoceles (SLs) compared with its extraperitoneal counterpart (eRARP) when bilateral pelvic lymph node dissection (BPLND) is performed. In this study, we aim to determine if there is a difference in SL formation and characteristics between the two approaches. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent eRARP or tRARP and BPLND by a single surgeon at a tertiary care academic center from July 1, 2003, to May 31, 2016. Patients with a history of prior pelvic radiotherapy, concomitant inguinal hernia repair, RARP without BPLND, or nonadenocarcinoma of the prostate were excluded. The resulting eRARP and tRARP groups were propensity matched for age, body mass index (BMI), American Association of Anesthesiologists (ASA) score, D'Amico risk classification, and pathological lymph node (LN) count. RESULTS: A total of 3183 RARPs were performed during this time period. After applying exclusion criteria and propensity score matching, 671 patients remained in each group. No statistically significant differences were noted between the groups with regard to age, BMI, ASA, pre-RARP prostate-specific antigen, D'Amico risk classification, biopsy and pathological Gleason sum score, pathological T stage, or margin status. The tRARP group had a higher clinical T stage (p = 0.0015), length of stay (LOS; p = 0.005), pathological N stage (4.92% vs 1.36%, p = 0.0002), and high total LN count (7.22 ± 5.54 vs 5.78 ± 4.18 LNs, p < 0.0001). The eRARP group had higher operating room times (197.4 ± 48.96 minutes vs 192.2 ± 44.12 minutes, p = 0.04) and estimated blood loss (218.4 ± 152.0 mL vs 179.9 ± 119.4 mL, p < 0.0001). No differences were noted in the frequency of SL formation [eRARP: 19/671 (2.83%) vs tRARP: 10/671 (1.49%), p = 0.09] or any clinical characteristics of the SL. Logistic regression analysis showed no effect of LN count (p = 0.071), pathological N stage (p = 0.111), or both combined (p = 0.085) on SL formation. CONCLUSIONS: In this cohort, the rate and clinical characteristics of SL were similar among patients treated with eRARP or tRARP and BPLND. The low event rate of SL in each group and trends favoring higher SL with LN yield and pN1 disease in the tRAPR group may deem the study underpowered to make definitive conclusions.

Extraperitoneal vs Transperitoneal Robot-Assisted Radical Prostatectomy in the Setting of Prior Abdominal or Pelvic Surgery.

INTRODUCTION: During robot-assisted radical prostatectomy (RARP), the prostate may be approached extraperiteoneally (extraperitoneal robot-assisted radical prostatectomy [eRARP]) or transperitoneally (transperitoneal robot-assisted radical prostatectomy [tRARP]). The former avoids the abdominal cavity, which might be of benefit in patients who have had prior abdominal or pelvic surgery (PAPS). Our objective was to compare the outcomes of patients with PAPS undergoing either technique. METHODS: A retrospective review of patients treated with RARP from July 1, 2003 to December 31, 2014 with a minimum follow-up of 3 months was undertaken. Of 2927 patients, 620 were identified as having undergone RARP (without concomitant unrelated procedures) and PAPS (excluding patients with prior inguinal hernia repair with mesh or unclear surgical histories) for prostate adenocarcinoma without prior pelvic radiotherapy. Of these, 340 patients underwent eRARP and 280 patients underwent tRARP. RESULTS: Patients in the eRARP group were younger (61.04 years vs 62.32, p = 0.02), had a higher body mass index (29.65 vs 28.98, p = 0.09), lower American Society of Anesthesiologists scores (p = 0.03), and lower D'Amico risk classification disease (p < 0.0001). The two groups had similar rates of 1, 2, and >2 PAPS. On univariate analysis, the eRARP group had lower operative time (188.96 minutes vs 197.92 minutes, p = 0.003), extensive lysis of adhesions (0.9% vs 14.3%, p < 0.0001), length of hospital stay (LOS) (1.13 days ±0.45 vs 1.33 day ±1.08, p = 0.003), and higher estimated blood loss (210.74 mL vs 190.79 mL, p = 0.06). The eRARP group had a lower rate of gastrointestinal complications (0% vs 3.21%, p = 0.0007), a trend toward lower early post-operative complications (8.53% vs 12.86%, p = 0.08), and lower overall complications (9.41% vs 15%, p = 0.03). In regression analysis with model selection, only LOS was lower in the eRARP group (p = 0.02). CONCLUSIONS: Both methods are safe in patients with prior abdominal surgeries. A lower incidence of gastrointestinal complications and a shorter length of stay were noted in the extraperitoneal cohort.

Extraperitoneal vs. transperitoneal robot-assisted radical prostatectomy in patients with a history of prior inguinal hernia repair with mesh.

Robot-assisted radical prostatectomy (RARP) may be performed via an extraperitoneal (eRARP) or transperitoneal (tRARP) approach. There are no published studies comparing these two methods in patients with a history of prior inguinal hernia repair with mesh (IHRm), but the latter is often advocated in this setting. A retrospective review of patients who underwent RARP with prior IHRm who had a minimum follow-up of 3 months from July 1, 2003 to December 31, 2014 was undertaken. Of 2927 patients who underwent RARP for primary treatment of adenocarcinoma of the prostate, 286 patients had a clear history of IHRm. Of these, 116 patients underwent eRARP and 170 patients underwent tRARP. No differences were noted between the groups with respect to age, body mass index or American Society of Anesthesiology score. Patients in the tRARP group had higher D'Amico risk classification scores (p < 0.0001) and as such, underwent less nerve-sparing procedures (p < 0.0001) and had a higher rate of concomitant pelvic lymph node dissections (p < 0.0001). The tRARP group had a higher incidence of laparoscopic and bilateral IHRm. On univariate analysis, EBL was lower in the tRARP group (172.41 vs. 201.98, p = 0.05) but all other parameters were similar. After controlling for covariates using regression analysis with model selection, a trend was noted towards lower operating room time in the tRARP group (p = 0.0624) but no other differences were noted. The presence of prior IHRm does not seem to be a contraindication to eRARP. OR time may be lower with tRARP (trend) but all other quality indicators studied were similar.