Primary robotic RLPND for nonseminomatous germ cell testicular cancer: a two-center analysis of intermediate oncologic and safety outcomes.

OBJECTIVE: To evaluate the intermediate-term oncologic outcomes and safety profile of the largest case series of primary robotic retroperitoneal lymphadenectomy for low-clinical-stage non-seminomatous germ cell testicular cancer. METHODS: This was a two-center retrospective analysis of robotic RPLND cases for low-clinical-stage (stage I-IIB) non-seminomatous germ cell testicular cancer in the primary setting. Demographic, perioperative, operative and oncologic variables were collected between March 2008 and May 2019. Descriptive analyses were performed and presented as medians with interquartile ranges for continuous variables and frequency and proportions for categorical variables. A survival analysis of time to recurrence was performed using Cox proportional hazards model. Using logistic regression, risk factors for complications were analyzed. Both univariate and multivariate analyses were performed. RESULTS: A total of 58 patients (CS 1 = 56, CS IIA = 2, CS IIB = 0) were identified. The median follow-up was 47 months and the 2-year recurrence-free survival rate was 91%. The five recurrences were all out of the performed dissection template (pelvis = 1 and lung = 4). Only five patients (29%) with occult metastasis underwent adjuvant chemotherapy. The median operative time was 319 min [interquartile range (IQR) 276-355 min], estimated blood loss was 100 ml (IQR 75-200 ml), node count was 26 (IQR 20-31), and length of stay 2 d (IQR 1-3 days). There were 2 (3.3%) intraoperative complications, 19 (32.7%) 30-day postoperative complications to include 14 (24.1%) Clavien grade I, 4 (6.9%) Clavien grade II, 1 (1.7%) Clavien grade III and 0 Clavien grade IV complications. No statistical significance was found on multivariate or univariate analysis for survival analysis of time to recurrence and risk factors for complications. CONCLUSIONS: This study represents the largest case series of primary R-RPLND for the treatment of low-stage non-seminomatous germ cell tumors (NSGCT). With 47 months of follow-up and a low rate of adjuvant chemotherapy, intermediate oncologic efficacy appears to be comparable to the gold standard open approach.

Survey of Sexual Function and Pornography.

INTRODUCTION: We aimed to explore and describe the pornography habits of young men and women. Given recent upward trends in pornography use and erectile dysfunction, along with a plausible pathophysiology, we hypothesized that pornography use would correlate with sexual dysfunction. MATERIALS AND METHODS: Institutional Review Board approval was obtained. Surveys were distributed to 20-40 year old men and women presenting to a urology clinic. Information was collected on demographics and medical history. Sexual function was evaluated with the International Index of Erectile Function (IIEF) in men and the Female Sexual Function Index in women. Extent of potential addiction to pornography was measured with the pornography craving questionnaire and the obsessive passion scale. Pornography use was measured based on both frequency and duration, and analyzed relative to sexual dysfunction. RESULTS: Men used pornography significantly more frequently than women (81.1% vs. 39%). Computer and cellular phone image viewing were the most popular modalities in both sexes. There was no association between IIEF and craving for, or obsessive passion for, pornography. Preference for pornography with masturbation was found to be significantly associated with erectile dysfunction (p = 0.001). Rates of erectile dysfunction were lowest in those preferring partnered sex without pornography (22.3%) and increased significantly when pornography was preferred over partnered sex (78%). No correlation was found between any variables and female sexual dysfunction. CONCLUSIONS: Pornography and sexual dysfunction are common among young people. No clear relationship exists between extent of addiction to pornography and sexual dysfunction in either gender. However, men who prefer masturbation with pornography to partnered sex have a significantly increased risk of sexual dysfunction. Given sexual dysfunction may be associated with mental health concerns, further evaluation of its causes and impact on military operational readiness are warranted.

Comparison of retroperitoneal and transperitoneal robotic partial nephrectomy for Pentafecta perioperative and renal functional outcomes.

BACKGROUND: We compared quality outcomes between transperitoneal (TRPN) and retroperitoneal robotic partial nephrectomy (RRPN). METHODS: Two-center retrospective analysis of TRPN and RRPN from 10/2009 to 10/2015. Perioperative/renal function outcomes were analyzed. Primary endpoint was Pentafecta, a composite measure of quality [negative margin, no 30-day complication, ischemia time ≤25 min, return of glomerular filtration rate (eGFR) to >90% from baseline at last follow-up, and no chronic kidney disease upstaging]. Multivariable analysis (MVA) for factors associated with lack of optimal outcome was performed. RESULTS: 404 patients (TRPN 263, RRPN 141) were analyzed. Comparing TRPN vs. RRPN, mean tumor size (3.1 vs. 2.9 cm, p = 0.122) and RENAL score (7.4 vs. 7.2, p = 0.503) were similar. Most TRPN were anterior (65.0%) and most RRPN posterior (65.3%, p < 0.001). Operative time (p = 0.001) was less for RRPN. No significant differences between TRPN vs. RRPN were noted for ischemia time (23.1 vs. 22.8 min, p = 0.313), blood loss (p = 0.772), positive margins (p = 0.590), complications (p = 0.537), length of stay (p = 0.296), ΔeGFR (p = 0.246), eGFR recovery to >90% (55.9 vs. 57.4%, p = 0.833), and lack of CKD upstaging (84.0 vs. 87.2%, p = 0.464). Pentafecta rates were not significantly different (TRPN 33.9 vs. RRPN 43.3%, p = 0.526). MVA revealed increasing RENAL score (OR 1.5, p < 0.001) and decreasing baseline eGFR (OR 2.4, p = 0.017) as predictive for lack of Pentafecta. CONCLUSIONS: TRPN and RRPN have similar quality outcomes, though RRPN may offer modest benefit for operative time and have utility in posterior tumors. Association of increasing RENAL score and decreased baseline eGFR with lack of Pentafecta suggests dominant role of non-modifiable factors.

Robot-assisted vasovasostomy using a single layer anastomosis.

Of all patients who have vasectomies performed in the United States, upwards of 6% will pursue a vasectomy reversal. Currently, the gold-standard reversal procedure is a microscopic vasovasostomy utilizing either a one or two-layer vasal anastomosis. Unfortunately, most urologists do not perform these procedures as they require extensive training and experience in microsurgery. The objective of our study was to evaluate the feasibility and success rate of robot-assisted vasovasostomy performed at our institution. We completed a retrospective review of our experience with vasectomy reversal utilizing the da Vinci® Surgical System and a single layer vasal anastomosis. A successful reversal was defined as a return of sperm on semen analysis or light microscopy. Since 2009 we have completed 79 robotic vasectomy reversals, 60 of which utilized a single-layer vasal anastomosis. The average obstructive interval was 5.7 ± 2.2 years. Average operative time was 192 min. 42 patients returned for a post-operative semen evaluation at an average time of 4.3 months post-procedure revealing a success rate of 88% (37 out of 42). Post-operative semen parameters were significant for an average sperm density of 31.0 million/mL with an average motility of 29.1%. Robot-assisted vasovasostomy with a single layer anastomosis has overall success rates that are similar to that of reported microscopic vasovasostomy rates. Although more study is warranted with regard to cost, we feel as though our study demonstrates an alternative approach to vasectomy reversal that can be performed successfully by urologists trained in robotic surgery.