Outcomes of lateral approach in robot-assisted radical prostatectomy: insights from a single-surgeon experience.

In the era of robotic prostate surgery, various techniques have been developed to improve functional outcomes. Urinary continence has shown satisfactory results, but the preservation of lateral nerves to the periprostatic capsule is only achievable by sparing the pubovesical complex. This study aims to present the first cases of lateral-approach robot-assisted radical prostatectomy (LRRP) performed by a novice surgeon. We conducted a retrospective analysis of 70 prostate cancer patients who underwent LRRP between October 2019 and September 2021, analyzing the perioperative and functional outcomes. The median operative time and intraoperative blood loss were 102 (92-108) minutes and 150 (130-180) mL, respectively. Five minor postoperative complications were reported, and the median hospital stay was 2 (1-2) days. Eleven positive surgical margins occurred. Potency and urinary continence recovery were achieved in 59 (84%) and 66 (94%) patients, respectively, 12 months after surgery. Our analysis shows that LRRP is a safe and effective procedure for prostate cancer surgery. Continence and potency recovery required a short learning curve, with an acceptable recovery rate even in the initial cases.

First case-series of robot-assisted pudendal nerve release: technique and outcomes.

OBJECTIVE: Pudendal Nerve Entrapment (PNE) may determine chronic pelvic pain associated with symptoms related to its innervation area. This study aimed to present the technique and report the outcomes of the first series of robot-assisted pudendal nerve release (RPNR). PATIENTS AND METHODS: 32 patients, who were treated with RPNR in our centre between January 2016 and July 2021, were recruited. Following the medial umbilical ligament identification, the space between this ligament and the ipsilateral external iliac pedicle is progressively dissected to identify the obturator nerve. The dissection medial to this nerve identifies the obturator vein and the arcus tendinous of the levator ani, which is cranially inserted into the ischial spine. Following the cold incision of the coccygeous muscle at the level of the spine, the sacrospinous ligament is identified and incised. The pudendal trunk (vessels and nerve) is visualized, freed from the ischial spine and medially transposed. RESULTS: The Median duration of symptoms was 7 (5, 5-9) years. The median operative time was 74 (65-83) minutes. The median length of stay was 1 (1-2) days. There was only a minor complication. At 3 and 6 months after surgery, a statistically significant pain reduction has been encountered. Furthermore, the Pearson correlation coefficient reported a negative relationship between the duration of pain and the improvement in NPRS score, - 0.81 (p = 0.01). CONCLUSIONS: RPNR is a safe and effective approach for the pain resolution caused by PNE. Timely nerve decompression is suggested to enhance outcomes.

Robotic radical prostatectomy: analysis of midterm pathologic and oncologic outcomes: A historical series from a high-volume center.

BACKGROUND: Identifying predictors of positive surgical margins (PSM) and biochemical recurrence (BCR) after radical prostatectomy (RP) may assist clinicians in formulating prognosis. Aim of the study was to report the midterm oncologic outcomes, to identify the risk factors for PSM and BCR and assess the impact of the PSM on BCR-free survival following robot-assisted laparoscopic radical prostatectomy (RALP). METHODS: From 2005 to 2010, 1679 consecutive patients underwent transperitoneal RALP. Data was retrospectively collected by an independent statistical company and analyzed in 2014. Median postoperative follow-up was 33.5 mo. BCR was defined as any detectable serum prostate-specific antigen (PSA) ≥ 0.2 ng/mL in two consecutive measurements. BCR-free survival was estimated using the Kaplan-Meier method. Univariate and multivariate analysis were applied to identify risk factors for PSM and BCR. RESULTS: In pN0/pNx cancers, pathologic stage was pT2 in 1186 patients (71.8%), pT3 in 455 patients (27.6%), and pT4 in 11 patients (0.6%). PSM rate was 17.4% and 36.9% of pT2 and pT3 cancers, respectively. Pathologic Gleason score was < 7, = 7 and > 7 in 42.1%, 53% and 4.9% of the patients, respectively. Overall BCR-free survival was 73.1% at 5 years; the 5-year BCR-free survival was 87.9% for pT2 with negative surgical margins. PSA, Gleason score (both bioptic and pathologic), pathologic stage (pT) and surgeon's volume were significant independent predictors of PSM. PSA, pathologic Gleason score, pT and PSM were significant independent predictors of BCR-free survival. Seminal vesicle-sparing, nerve-sparing approach and the extent of nerve-sparing (intra vs interfascial dissection) did not negatively affect margin status or BCR rates. CONCLUSIONS: PSMs are a predictor of BCR. Being the only modifiable factor influencing the PSM rate, surgical experience is confirmed as a key factor for high-quality oncologic outcomes.

Comparison of micro-ultrasound and multiparametric magnetic resonance imaging for prostate cancer: A multicenter, prospective analysis.

INTRODUCTION: High-resolution micro-ultrasound has the capability of imaging prostate cancer based on detecting alterations in ductal anatomy, analogous to multiparametric magnetic resonance imaging (mpMRI). This technology has the potential advantages of relatively low cost, simplicity, and accessibility compared to mpMRI. This multicenter, prospective registry aims to compare the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of mpMRI with high-resolution micro-ultrasound imaging for the detection of clinically significant prostate cancer. METHODS: We included 1040 subjects at 11 sites in seven countries who had prior mpMRI and underwent ExactVu micro-ultrasound-guided biopsy. Biopsies were taken from both mpMRI targets (Prostate Imaging-Reporting and Data System [PI-RADS] >3 and micro-ultrasound targets (Prostate Risk Identification using Micro-ultrasound [PRIMUS] >3). Systematic biopsies (up to 14 cores) were also performed. Various strategies were used for mpMRI target sampling, including cognitive fusion with micro-ultrasound, separate software-fusion systems, and software-fusion using the micro-ultrasound FusionVu system. Clinically significant cancer was those with Gleason grade group ≥2. RESULTS: Overall, 39.5% were positive for clinically significant prostate cancer. Micro-ultrasound and mpMRI sensitivity was 94% vs. 90%, respectively (p=0.03), and NPV was 85% vs. 77%, respectively. Specificities of micro-ultrasound and MRI were both 22%, with similar PPV (44% vs. 43%). This represents the initial experience with the technology at most of the participating sites and, therefore, incorporates a learning curve. Number of cores, diagnostic strategy, blinding to MRI results, and experience varied between sites. CONCLUSIONS: In this initial multicenter registry, micro-ultrasound had comparable or higher sensitivity for clinically significant prostate cancer compared to mpMRI, with similar specificity. Micro-ultrasound is a low-cost, single-session option for prostate screening and targeted biopsy. Further larger-scale studies are required for validation of these findings.

Laparoscopic Management of Pelvic Organ Prolapse in a Kidney Transplant Recipient.

This is a report of a laparoscopic double mesh sacrocolpopexy performed in the setting of a 73-year-old woman carrying a grafted kidney. The patient had a vaginal prolapse of the anterior and posterior floor without urinary incontinence. Despite immunosuppression due to anti-rejection treatments and the presence of kidney transplant in left iliac fossa, laparoscopic intervention with the introduction of prosthetic material was conducted. The intervention showed no major difficulty in its implementation and the postoperative course was uneventful. The long-term follow-up will confirm the tolerance of a prosthetic material.

[Minimally invasive radical prostatectomy: Contribution of robotic support, functional and oncological outcomes]. / Prostatectomie radicale mini-invasive : apport de l'assistance robotisée, résultats fonctionnels et oncologiques.

OBJECTIVES: Radical prostatectomy (RP) remains a standard for localized prostate cancer treatment. The objective of this study is to present this operating technique of the robot-assisted radical prostatectomy (PR-RA) and to evaluate oncological and functional results as well as on the surgical safety. METHODS: A first series of 1679 patients consecutively operated in our institution with this technique from 2005 to 2010 and with a 5-year follow-up evaluated in 2014. The oncology monitoring is ensured with a PSA test every six months during the first three years and once a year the years after if the level remains undetectable. RESULTS: The oncologic outcomes show 17.4% for pT2 stages and 36.9% for pT3 stages positive margins. The level of biological recurrence is 21.27% with an average delay of 88 months as the time needed for the recurrence to occur. At 12 months, urinary continence (0-1pad/day) returned at 94% of all patients and potency with successful penetration for all men is 61.1% and 88.8% for men with sexual activity before surgery. CONCLUSIONS: The technique PRRA seems to be a reliable technique whose functional results studied from meta-analysis seem to be superior in terms of rapidity of recovery of the continence and erection in comparison with classical surgical or laparoscopic approach.

Laparoscopic and robot-assisted continent urinary diversions (Mitrofanoff and Yang-Monti conduits) in a consecutive series of 15 adult patients: the Saint Augustin technique.

OBJECTIVE: To present a series of 15 laparoscopic and robot-assisted Mitrofanoff and Yang-Monti vesicostomies in an adult population, and to assess the feasibility and safety of these minimally invasive approaches. PATIENTS AND METHODS: Between 2009 and 2012, 15 patients underwent laparoscopic (n = 11) or robot-assisted (n = 4) construction of vesicostomy by a single surgeon (D.R.): Mitrofanoff appendicovesicostomy (n = 11) or double Yang-Monti ileal conduit (n = 4). Fourteen patients underwent concomitant augmentation enterocystoplasty. Indications for surgery included neurogenic bladder (n = 11) and urethral dysfunction (n = 4). The patients were evaluated postoperatively using cystography. Quality of life (QoL) was evaluated using an internally developed questionnaire. RESULTS: All surgeries were successfully completed with no conversions. Operating time was always <5 h. The mean estimated blood loss was 150 mL and the mean follow-up was 22 months. Early postoperative complications included deep retrovesical abscess (n = 2) and upper urinary tract infections (n = 4), and one patient had peri-operative cardiac failure. Late postoperative complications included stomal stenosis (n = 2), persistent low-pressure bladder incontinence (n = 1) and recurrent infections (n = 1). Surgical excision of the conduit was necessary in one patient. Postoperatively, patients showed complete bladder emptying and no leak on follow-up cystography. According to our QoL questionnaire, 13/15 patients did not regret the surgery. CONCLUSIONS: While a longer follow-up is needed to assess the durability of our results, this series shows that the laparoscopic and robot-assisted approaches for the construction of continent urinary diversions are feasible and safe in an adult population.

Feasibility of robotic double Yang-Monti ileal conduit with bladder augmentation: surgical technique.

OBJECTIVE: To report the feasibility of a novel robotic technique for intracorporeal construction of a double Yang-Monti ileal conduit with bladder augmentation in an adult patient. METHODS: The Yang-Monti procedure can be considered as an alternative to Mitrofanoff appendicovesicostomy when the appendix is not available or in obese patients. To date, the robotic approach has not been described. We have described all the steps of our surgery, performed on a 35-year-old obese patient with post-traumatic paraplegia and a neurogenic bladder. We focused on the technical tips and highlighted all the differences with the standard open technique. RESULTS: Our technique provided satisfactory results. No intraoperative complications occurred. The operative time was 250 minutes, and the intraoperative blood loss was 200 mL. The clinical course was uneventful. CONCLUSION: We have shown that robotic intracorporeal realization of a double Yang-Monti ileal conduit with bladder augmentation is feasible, extending the potential indications of robot-assisted surgery. The evaluation of more cases is advised.

[Post-traumatic high-flow priapism in an adolescent]. / Priapisme post-traumatique a haut débit chez un adolescent.

The authors report a case of high-flow priapism in an adolescent due to rupture of the deep penile artery after falling astride, confirmed by Doppler ultrasound on the third day after the accident, and treated successfully by highly selective embolization with no harmful effects on erectile function.