Off-Clamp Robot-Assisted Partial Nephrectomy: Is There Something More to Achieve Optimal Trifecta Outcomes?

Objectives: To report trifecta outcomes of our "off-clamp" partial nephrectomy (PN) patients operated without main renal artery and/or any selective/superselective clamping. Materials and Methods: Between April 2008 and March 2020, 52 patients received "off-clamp" robot-assisted partial nephrectomy. Postoperative sixth month estimated glomerular filtration rate (eGFR) and eGFR decrease were considered for renal function evaluation. Patients with negative surgical margins, <15% postoperative eGFR decrease and absence of grade ≥2 Clavien-Dindo complications were reported to achieve trifecta outcomes. Results: Mean age and body mass index of the patients were 57.51 ± 12.99 years and 27.23 ± 4.35 kg/m2, respectively. Mean preoperative hematocrit, serum creatinine, and eGFR were 42.01 ± 3.86%, 0.92 ± 0.28 mg/dL, and 85.26 ± 21.27 mL/min/1.73 m2, respectively. Mean tumor size was 30.32 ± 13.64 mm. Mean PADUA and RENAL scores were 7.63 ± 1.46 and 6.21 ± 1.63, respectively. One patient had focal surgical margin positivity. Mean console time and estimated blood loss was 82.11 ± 38.51 minutes and 280.76 ± 278.98 mL, respectively. Complications were observed in two (4%) patients (one Clavien I, one Clavien IIIB). At postoperative sixth month, serum creatinine and eGFR were 0.95 ± 0.32 mg/dL and 83.65 ± 22.44 mL/min/1.73 m2, respectively. Eventually seven patients had ≥15% postoperative eGFR decrease, one patient had grade ≥2 complication and one patient had positive surgical margin. Forty-three (83%) patients fulfilled trifecta outcomes. Conclusion: Off-clamp PN is important for optimal renal function preservation. Patient selection and additional operative measures along with experience in robotic procedure can contribute achievement of optimal trifecta outcomes.

Non-muscle invasive bladder cancer tissues have increased base excision repair capacity.

The molecular mechanisms underlying the development and progression of bladder cancer (BC) are complex and have not been fully elucidated. Alterations in base excision repair (BER) capacity, one of several DNA repair mechanisms assigned to preserving genome integrity, have been reported to influence cancer susceptibility, recurrence, and progression, as well as responses to chemotherapy and radiotherapy. We report herein that non-muscle invasive BC (NMIBC) tissues exhibit increased uracil incision, abasic endonuclease and gap-filling activities, as well as total BER capacity in comparison to normal bladder tissue from the same patient (p < 0.05). No significant difference was detected in 8-oxoG incision activity between cancer and normal tissues. NMIBC tissues have elevated protein levels of uracil DNA glycosylase, 8-oxoguanine DNA glycosylase, AP endonuclease 1 and DNA polymerase ß protein. Moreover, the fold increase in total BER and the individual BER enzyme activities were greater in high-grade tissues than in low-grade NMIBC tissues. These findings suggest that enhanced BER activity may play a role in the etiology of NMIBC and that BER proteins could serve as biomarkers in disease prognosis, progression or response to genotoxic therapeutics, such as Bacillus Calmette-Guérin.

A prospective comparative analysis of robot-assisted vs open simple prostatectomy for benign prostatic hyperplasia.

OBJECTIVE: To report the first prospective comparative analysis of robot-assisted (RASP) vs open simple prostatectomy (OSP) for large prostate glands. MATERIALS AND METHODS: We prospectively analysed 41 patients who underwent surgery for benign prostatic hyperplasia between 2014 and 2017 at one of two university institutions. Patients were grouped according to the procedure (OSP or RASP) and matched in terms of age, prostate volume, body mass index and prostate-specific antigen level. The two groups were followed prospectively for 3 months, and their postoperative and functional outcomes were compared. RESULTS: Six patients (40%) in the OSP and seven patients (27%) in the RASP arm of the study had preoperative urethral catheters as a result of relapsed urinary retention. The amount of blood loss during surgery was significantly lower in the RASP arm (539  vs 274 mL), but the operating time was significantly longer (134 vs 88 min). One patient in the RASP group experienced a Clavien-Dindo grade II complication, whereas in the OSP group, four patients experienced serious complications (27%); one patient had a bladder rupture (Grade III), one patient developed deep venous thrombosis (Grade II), and two patients required blood transfusions (one unit each; Grade II). Two patients (one from each group) experienced urinary retention after catheter removal that required a urethral catheter replacement. In the follow-up period, there were significant and similar improvements in International Prostate Symptom Scores, uroflowmetry results and post-void residual urine volume in both groups. CONCLUSION: The results showed that RASP provided similar functional outcomes to those of OSP, whilst maintaining a good (or even better) safety profile. Our results suggest that RASP is a viable, efficient and potentially superior alternative to the open procedure.

Intra-surgical total and re-constructible pathological prostate examination for safer margins and nerve preservation (Istanbul preserve).

PURPOSE: To demonstrate a novel frozen section analysis technique during robot assisted radical prostatectomy with 2 distinct advantages: evaluation of the entire circumference and easier reconstruction for whole mount evaluation. MATERIAL AND METHODS: Istanbul Preserve was performed on patients who underwent robotic prostatectomy with nerve sparing between 10/2014 and 7/2016. Gland was sectioned at 3-4mm intervals from apex to bladder neck. Entire tissue representing margins (except for the most anterior portion) was circumferentially excised and microscopically analyzed. In margin positivity, approach was individualized based on extent of positive margin and Gleason pattern. A matched cohort was established for comparison. Retrospective analysis of a prospectively maintained database was performed. Impact of FSA on PSM rate was primarily assessed. RESULTS: Data on 170 patients was analyzed. Positive surgical margin was reported in 56(33%) on frozen section. Neurovascular bundle was partially or totally resected in 79% and 18%. Conversion of positive margin to negative was achieved in 85%. Overall positive margin rate decreased from 22.5% to 7.5%. Nerve sparing increased from 87% to 93%. Location of positive margin at frozen was at the neurovascular bundle area in 39%; thus Istanbul Preserve detected 61% additional margin positivity compared to other techniques. Reconstruction for whole mount was easy. CONCLUSION: Istanbul Preserve is a novel technique for intraoperative FSA during RARP allowing for microscopic examination of the entire prostate for margin status and easy re-construction for whole mount examination. It guarantees safer margins together with increased rate of nerve sparing.

Minimizing Ports During Robotic Partial Nephrectomy.

BACKGROUND AND OBJECTIVE: Robotic upper urinary tract surgery is in most of the cases performed utilizing a standard 5 port configuration. Fewer ports can potentially produce a less invasive operation. Taking in consideration the above we report a novel technique for robot assisted laparoscopic partial nephrectomy utilizing fewer ports and we test its feasibility and safety profile. METHODS: Data on 11 robot-assisted laparoscopic partial nephrectomies performed by using our technique from February 2015 through June 2015 were retrospectively analyzed. The robotic platform used was DaVinci Xi (Intuitive Surgical, Inc., Sunnyvale, California, USA) with a 3-arm setup. The AirSeal system (SurgiQuest, Milford, Connecticut, USA) was used as a port allowing simultaneous introduction of 2 instruments for the bedside surgeon, obviating the need for an additional (fourth) robotic arm. A long suction-and-irrigation device and atraumatic grasping forceps were used. Both instruments were introduced through the trocar of the AirSeal system, making simultaneous introduction and use possible. We preferred the long suction-and-irrigation device, because it minimizes collision of the instruments. RESULTS: Mean age and BMI of the patients were 55 ±14.6 y and 29.18 ± 6.85, respectively. Seven tumors were on the right side and 4 were on the left. The mean size of the tumors was 32.45 mm (± 11.31). Surgical time was 132.2 minutes (±37.17), with an estimated blood loss and ischemia time of 103.63 mL (±65.92) and 16.72 minutes (±9.52), respectively. One patient had postoperative bleeding that was resolved without transfusion. The median hospitalization period was 3.9 d (±0.53). Loss of intra-abdominal pressure was not observed, and pressure was stable at 10 mm Hg. CONCLUSION: The AirSeal System and its valveless trocar eliminated the need for an additional port placement in our series. The technique is feasible, safe, and reproducible; therefore, it may be implemented in selected cases of robot-assisted partial nephrectomies.

Radical Nephroureterectomy Without Patient or Port Repositioning Using the Da Vinci Xi Robotic System: Initial Experience.

OBJECTIVE: To report our initial experience on robot-assisted radical nephroureterectomy, using the da Vinci Xi robotic system without patient or port repositioning. MATERIALS AND METHODS: The patients were in a modified flank position. A Bugbee electrode was used to cauterize and mark the ureteral orifice, aiding in the final robotic excision of the distal ureter. For the first step of the procedure, the second robotic arm holds the scope, the fourth robotic arm holds Port #1 (monopolar curved scissors), the first robotic arm holds Port #2 (Fenestrated bipolar forceps), and the third robotic arm holds Port #4 (Prograsp forceps). After completion of nephrectomy, all robotic arms were released and reconfigured. In the new setting, the third robotic arm and second robotic arm were switched between the camera port and the fourth port. The first port remained working with the monopolar curved scissors whereas Prograsp forceps was moved to the second port and fenestrated bipolar forceps was moved to the third port. RESULTS: Two patients underwent 2 successful radical nephroureterectomies with the above-mentioned technique. The console time for the first patient was 150 minutes whereas the estimated blood loss was 200 mL. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization time and catheter removal time were 3 days for both patients and no complications were observed. CONCLUSION: The use of the da Vinci Xi robotic system enabled us to perform both nephrectomy and distal ureterectomy and/or bladder cuff excision without any repositioning of the patient or trocars.

Presentation and prognosis of female acute urinary retention: Analysis of an unusual clinical condition in outpatients.

OBJECTIVES: Acute urinary retention (AUR) in females is a poorly defined condition with undetermined epidemiology. This study aimed to evaluate female AUR in an outpatient population. PATIENTS AND METHODS: One hundred and thirty-eight adult female outpatients who presented to the emergency room with symptoms of urinary retention were retrospectively analyzed. The women who were ultimately diagnosed with true, complete AUR were systematically reviewed for clinical characteristics and management. RESULTS: In this outpatient cohort with urinary retention complaints, only 23% of the patients were diagnosed with objective AUR. Detailed medical and urological history in addition to urogenital, neurological, and pelvic examinations was essential; urine analysis and pelvic ultrasonography were necessary as baseline investigations. Further radiological and urodynamic tests were required in a minority. Specific etiology was established in 77% of the patients, whereas there was more than one probable cause in 16% of the patients, and no specific cause was found in 6.5% of the patients. Bladder decompression and correction of the underlying cause helped 92.6% of the reviewed patients to eventually achieve spontaneous micturition. CONCLUSIONS: The proportion of true, complete AUR among female outpatients presenting to the emergency department was 23% following urological evaluation. Acute condition was resolved by urgent catheterization in all, and the majority of women had eventually resumed spontaneous voiding.

Nonprosthetic Direct Inguinal Hernia Repair During Robotic Radical Prostatectomy.

OBJECTIVE: To report our experience with concomitant hernia repair during robot-assisted radical prostatectomy (RARP) with a nonprosthetic and tissue-based technique. METHODS: We conducted a retrospective review on 1005 consecutive patients who underwent RARP between the years 2005 and 2015. Twenty-nine patients, who underwent 37, concurrent, direct, inguinal hernia repairs, were identified (group 1) and compared to a match control group of 29 patients who underwent RARP without hernia repair (group 2). Cases were matched 1:1 for age, body-mass index, and pathologic stage. The reinforcement of the floor was achieved with a modified posterior wall darn repair. The repair consisted of suturing the lateral edge of the rectus abdominis muscle sheath to the ileopectineal ligament (Cooper's ligament) with continuous prolene loose suture. This technique provided a tissue-based repair and the final reinforcement of the floor was expected to ensue by the secondary fibrotic tissue development and maturing between the sutures. RESULTS: From a total of 1005 patients who underwent RARP, 29 (2.8%) were preoperatively identified with a primary, direct inguinal hernia and underwent concomitant inguinal herniorrhaphy. The operative time was 147 minutes for group 1 vs 143 minutes for group 2 (p = 0.8). Estimated blood loss was 175 mL for the group with the hernia repair vs 200 mL for the group without repair (p = 0.3). There were no Clavien-Dindo grade >1 complications observed in either of the groups. Mean follow-up period was 32.1 months for group 1 vs 33.3 for group 2 (p = 0.8). Importantly, no hernia recurrences were observed. CONCLUSIONS: Inguinal hernias represent an important surgical issue and may be repaired concurrently during radical prostatectomy to minimize the risks of postoperative complications. The concomitant repair of inguinal hernias during robotic radical prostatectomy utilizing a nonprosthetic is a safe and feasible alternative for primary direct hernia repair during prostatectomy.

The use of a bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy.

Optimal control of the dorsal venous complex (DVC) is a critical step in robot-assisted radical prostatectomy (RARP). If DVC is not controlled properly, bleeding may occur during the apical dissection. On the other hand, if it is controlled well, a bloodless field is attained and, thus, a precise apical dissection and urethral division is possible. Suture ligation is the most common technique used for dorsal vein control, while some authors recommend using an endovascular stapler. Recently, athermal division and selective suture ligation technique has been reported for DVC control. We describe a new technique: Use of a bulldog clamp to control the DVC during RARP. The control of the DVC with a bulldog clamp allows a bloodless field with precise apical dissection and provides preservation of maximum urethral length while avoiding sphincteral injury.

Can the outcome of autoaugmentation omentocystoplasty be improved? Urodynamic, histological, and collagen content evaluation in sheep model.

AIM: To compare histological and urodynamic outcome of the classical detrusorotomy with and without the aid of intravesical balloon distension. We also describe a new technique with multiple detrusor incisions instead of detrusorotomy. METHODS: A total of 24 animals were included in the study. Three different techniques of autoaugmentation cystoplasty were applied to surgically reduced bladders of 14 sheep. Five sheep underwent surgical reduction of bladder capacity as control group and five sheep underwent sham operation. In Group DIB (detrusor incision with balloon), standard whole thickness incisions on bladder wall were performed and a silicon balloon was inflated intravesically postoperatively. Group DMB (detrusorotomy with balloon) and Group DM (detrusorotomy) underwent standard detrusorotomy. After measuring capacities and compliances, animals were sacrificed on 90th postoperative day. Bladders were histopathologically evaluated. Expression of vascular endothelial growth factor (VEGF), CD31, and microvessel density (MVD) was noted. Quantification of collagen subtypes was also performed. RESULTS: The mean capacity and compliance for Group DM and control were not significantly different and both were lower than other augmentation groups and sham. In Groups DMB and DM fibrosis was significantly increased. The VEGF expression was lower in Group DIB with respect to other augmentation groups whereas MVD was not significantly different. Measurement of total collagen and collagen subtypes revealed an increase in total collagen of groups DMB and DM when compared to other groups. Quantification of collagen subtypes demonstrated that types I and III were significantly increased in aforementioned groups. CONCLUSION: Autoaugmentation omentocystoplasty in sheep model does not result in a reliable increase in bladder capacity and compliance. Intravesical balloon inflation makes the achievement more pronounced and significantly increases the bladder capacity and compliance.

Comparison of the self-reported training level between Mexican and Western Europe residents in urology: results of an international survey.

OBJECTIVE: To find out how Mexican residents in urology perceive their own level of training in comparison with how residents in Europe perceive theirs. METHODS: A questionnaire of self-assessment was distributed to 104 European and 24 Mexican urologists-in-training. We assessed the perception of residents about their level of training and factors associated with self-perceived performance. RESULTS: Mean age of 128 residents was 32.69 +/- 3.33 years. Mexican residents spent significantly more time in urological departments than European residents. The weekly amount of hours spent at work was higher in Europe; while the number of residents per hospital was higher in Mexico. Mexican residents reported more reliable support from a supervising senior. European residents perceived they had a superior level regarding transplantation in female urology and urinary lithiasis, whereas Mexican residents felt more confident regarding urological infections and paediatric urology. Factors associated with better self-perceived performance were the number of months in urology, the number of non-urologic rotations and a supervising senior. CONCLUSION: Mexican residents in urology perceive that their own level of training is similar to that of European residents. The number of months of training in urology, the number of non-urologic rotations and a supporting senior are associated with a better self-perceived performance.

[Is the surgical training of French urologists more effective than that of urologists in other European countries?]. / La formation chirurgicale des urologues français est-elle plus efficace que celle des autres pays européens?

OBJECTIVE: To compare the level of surgical training of French interns with that of interns in other European countries. MATERIAL AND METHODS: Between 2005 and 2006, an exhaustive questionnaire (www.esnz.net) was sent to 288 young urologists in 30 different European countries. Interns were classified into 3 groups: France (group 1, n = 28), Western Europe (group 2, n = 75) and Eastern Europe (group 3, n = 85). Items concerning surgical practice were analysed. RESULTS: The mean age of the interns was 30.8 years (25.7-35.8), 34.6 years (27.4-48.0) and 31.3 years (25.3-51.3) in groups 1 to 3, respectively. The mean number of months of urology training was 28 months (6-60), 44 months (6-72) and 37 months (2-120), respectively. The mean of weekly working time was 70 hours (40-90), 60 hours (35-90) and 65 hours (40-100). French interns were technically more at ease than interns in groups 2 or 3 for all surgical procedures (open, laparoscopic, endourological). Certain criteria were significantly (p < 0.05) associated with a better level of technical skills: the number of weekly working hours, the small number of interns per department, the diversity of internships, the use of the intern record and the presence of an active tutor CONCLUSION: French interns appear to learn urological surgical procedures more easily than other European interns. However the scientific training of interns must also be evaluated in order to propose a global assessment system of urology training in Europe.

Significance of age-specific creatinine levels at presentation in posterior urethral valve patients.

OBJECTIVE: Determination of prognostic factors is of great importance in decision making on therapies and informing parents about the probable outcome of disease. The present study aims to evaluate and assess the prognostic factors in posterior urethral valve (PUV) patients. MATERIALS AND METHODS: The data of 68 patients treated between 1996 and 2004 were evaluated retrospectively. The mean age at diagnosis was 36.4 months. The serum creatinine levels were standardized using the age-specific creatinine reference (ASCR) levels. The age at diagnosis, clinical presentation, initial serum creatinine, method of treatment, presence of vesicoureteral reflux (VUR) and hydroureteronephrosis (HUN), all of which may effect the prognosis, were evaluated. RESULTS: The analysis revealed that, of the 36 patients whose initial serum creatinine levels were within ASCR, only one (2.8%) had a final serum creatinine higher than ASCR values. In contrast, of the 32 patients whose initial serum creatinine levels were not within ASCR, 19 (59.4%) had final serum creatinine levels higher than ASCR (P<0.001). The distribution of final serum creatinine according to treatment method, presence of UTI before treatment and age at diagnosis was not statistically significant; however, the difference in distribution for initial serum creatinine (P<0.001), mode of clinical presentation (0.016), presence of HUN (0.019) and state of VUR (0.037) before treatment was statistically significant. CONCLUSION: Final outcome with regard to renal function in PUV patients is affected by bilateral VUR and most significantly by serum creatinine levels higher than ASCR.