Postoperative Outcomes and Analgesic Requirements of Single-Port vs Multiport Robotic-Assisted Radical Cystectomy.

Objective: To compare outcomes in patients undergoing robotic-assisted radical cystectomy (RARC) with urinary diversion for bladder cancer with either the single-port (SP) or multiport (MP) robotic platform. Methods: All patients who underwent SP and MP RARC at our institution between January 2018 and January 2023 were retrospectively reviewed. Postoperative analgesia was administered by a departmentwide narcotic stewardship protocol, and inpatient and outpatient narcotic use was tracked. The available preoperative clinical, operative, and postoperative outcomes were analyzed using t-test, chi-square, and Fischer exact statistical measures. Kaplan-Meier analysis with log-rank testing was used to determine the freedom from high-grade (Clavien-Dindo grade ≥3) postoperative complications stratified by SP or MP robotic use. Results: Overall, 96 patients underwent RARC with urinary diversion at our institution, with 49 MP and 47 SP procedures performed. Preoperative clinical parameters including age, body mass index, prior abdominal surgery, and use of neoadjuvant chemotherapy were similar between the two groups. Patients undergoing SP RARC had a shorter operative time (386.0 ± 90.9 minutes vs 453.6 ± 94.8 minutes, p < 0.01) and faster return of bowel function (3.4 ± 1.4 days vs 4.5 ± 2.2 days, p < 0.01). However, both cohorts had similar length of hospitalization, postoperative narcotic use, pathologic staging, and rate of positive surgical margin. Within 3 months postoperatively, both cohorts had a similar high-grade complication, hospital readmission, and cancer recurrence rate. Conclusions: The SP robot allows a safe alternative surgical approach for RARC and offers similar postoperative outcomes compared to the MP robot.

Complications of single-port robot-assisted radical prostatectomy: multi-institutional analysis from the Single-Port Advanced Research Consortium (SPARC).

OBJECTIVE: To evaluate the perioperative complications of single-port robot-assisted radical prostatectomy (SP-RARP). PATIENTS AND METHODS: A retrospective review was performed on the prospectively maintained, Institutional Review Board-approved, multi-institutional Single-Port Advanced Research Consortium (SPARC) database. A total of 1103 patients were identified who underwent three different approaches of SP-RARP between 2019 and 2022 using the purpose-built SP robotic platform. In addition to baseline clinical, perioperative outcomes, this study comprehensively analysed for any evidence of intraoperative complication, as well as postoperative complication and readmission within 90 days of the respective surgery. RESULTS: Of the 244, 712, and 147 patients who underwent transperitoneal, extraperitoneal, and transvesical SP-RARP, respectively, intraoperative complications were noted in five patients (0.4%), all of which occurred during the transperitoneal approach. Two patients had bowel serosal tears, two had posterior button-holing of the bladder necessitating repair, and one patient had an obturator nerve injury. Postoperative complications were noted in 143 patients (13%) with major complications (Clavien-Dindo Grade ≥III) only identified in 3.7% of the total cohort. The most common complications were lymphocele (3.9%), acute urinary retention (2%), and urinary tract infection (1.9%). The 90-day re-admission rate was 3.9%. CONCLUSION: The SP-RARP is a safe and effective procedure with low complication and readmission rates regardless of the approach. These results are comparable to current multi-port RARP literature.

Low Risk of Postoperative Hernia Following Single-port Robot-assisted Radical Prostatectomy: A Report From the Single-port Advanced Research Consortium (SPARC).

OBJECTIVE: To evaluate the risk of postoperative hernia following different approaches of single-port robot-assisted radical prostatectomy (SP-RARP). METHODS: A retrospective review was performed on patients who underwent SP-RARP between February 2019 and December 2022. Demographic and clinical information was collected from the multi-institutional, prospectively-maintained Single-Port Advanced Research Consortium (SPARC) database. Data were analyzed using IBM Statistical Packaging for Social Sciences (SPSS) version 29.0 with descriptive statistics as presented. RESULTS: A total of 1103 patients were identified, consisting of 244 (22.1%), 712 (64.6%), and 147 (13.3%) cases performed via transperitoneal, extraperitoneal (EP), and transvesical (TV) approaches, respectively. During a median follow-up time of 11 months (interquartile range 5.7-17.1 months), only two cases of incisional hernia were reported. Both cases occurred following transperitoneal SP-RARP with one patient requiring surgical repair. There remains no evidence of postoperative hernia following EP and TV SP-RARP at the completion of our review. CONCLUSION: SP-RARP was associated with low risk for postoperative hernia. The risk was lower following TV and EP SP-RARP where the peritoneum is preserved.

Prostate Stereotactic Body Radiation Therapy With a Focal Simultaneous Integrated Boost: 5-Year Toxicity and Biochemical Recurrence Results From a Prospective Trial.

PURPOSE: Stereotactic body radiation therapy (SBRT) is increasingly used as a definitive treatment option for patients with prostate adenocarcinoma. The aim of this study was to assess the late toxicity, patient-reported quality of life outcomes, and biochemical recurrence rates after prostate SBRT with simultaneous integrated boost (SIB) targeting lesions defined by magnetic resonance imaging (MRI). METHODS AND MATERIALS: Patients were eligible if they had biopsy-proven low- or intermediate-risk prostate adenocarcinoma, one or more focal lesions on MRI, and an MRI-defined total prostate volume of <120 mL. All patients received SBRT delivered to the entire prostate to a dose of 36.25 Gy in 5 fractions with an SIB to the lesions seen on MRI to 40 Gy in 5 fractions. Late toxicity was defined as any possible treatment-related adverse event occurring after 3 months from the completion of SBRT. Patient-reported quality of life was ascertained using standardized patient surveys. RESULTS: A total of 26 patients were enrolled. Six patients (23.1%) had low-risk disease and 20 patients had intermediate-risk disease (76.9%). Seven patients (26.9%) received androgen deprivation therapy. Median follow-up was 59.5 months. No biochemical failures were observed. Three patients (11.5%) experienced late grade 2 genitourinary (GU) toxicity requiring cystoscopy, and 7 patients (26.9%) had late grade 2 GU toxicity requiring oral medications. Three patients (11.5%) had late grade 2 gastrointestinal toxicity characterized by hematochezia requiring colonoscopy and steroids per rectum. There were no grade 3 or higher toxicity events observed. The patient-reported quality-of-life metrics at the time of last follow-up were not significantly different than the pre-treatment baseline. CONCLUSIONS: The results of this study support that SBRT to the entire prostate to a dose of 36.25 Gy in 5 fractions with focal SIB to 40 Gy in 5 fractions has excellent biochemical control and is not associated with undue late gastrointestinal or GU toxicity or long-term quality of life decrement. Focal dose escalation with an SIB planning approach may be an opportunity to improve biochemical control while limiting dose to nearby organs at risk.

Are markers of survival associated with perioperative outcomes for tumor thrombectomy patients?

INTRODUCTION: Despite modern advances in surgical and perioperative technologies, management of renal cell carcinoma (RCC) with tumor thrombus (TT) is a morbid procedure that necessitates careful patient selection. It is not known whether established prognostic models for metastatic RCC are suitable prognostic tools for more immediate perioperative outcomes in patients with RCC with TT. We evaluated if established risk models for cytoreductive nephrectomy, as a potential extension of their purpose-built use, are associated with immediate perioperative outcomes in patients undergoing nephrectomy and tumor thrombectomy. METHODS: Perioperative outcomes of patients who underwent radical nephrectomy and tumor thrombectomy for RCC were compared to presences of established predictors of long-term outcomes from prior risk models individually and as stratified by risk grouping (International Metastatic Renal-Cell Carcinoma Database Consortium [IMDC], Memorial Sloan Kettering Cancer Center [MSKCC], M.D. Anderson Cancer Center [MDACC], and Moffitt Cancer Center [MCC]). Wilcoxon rank-sum test or the Kruskal-Wallis test compared continuous variables and the chi-square test or Fisher's exact test compared categorical variables. RESULTS: Fifty-five patients were analyzed with 17 (30.9%) being cytoreductive. Eighteen (32.7%) patients had a level III or higher TT. Individually, preoperative variables were inconsistently associated with perioperative outcomes. Poorer risk patients per the IMDC model had more major postoperative complications (Clavien-Dindo grade≥3, P = 0.008). For the MSKCC model, poorer risk patients had increased intraoperative estimated blood loss (EBL), longer length of stay (LOS), more major postoperative complications, and more likely to discharge to a rehabilitation facility (P < 0.05). Less favorable risk patients per MDACC model had increased LOS (P = 0.038). Poorer risk patients per the MCC model had increased EBL, LOS, major postoperative complications, and 30-day hospital readmissions (P < 0.05). CONCLUSION: Overall, cytoreductive risks models were heterogeneously associated with perioperative outcomes in patients undergoing nephrectomy and tumor thrombectomy. Of available models, the MCC model is associated with more perioperative outcomes including EBL, LOS, major postoperative complications, and readmissions within 30 days when compared to the IMDC, MSKCC, and MDACC models.

Single-port Extraperitoneal and Transperitoneal Radical Prostatectomy: A Multi-Institutional Propensity-Score Matched Study.

OBJECTIVE: To compare the perioperative and early postoperative outcomes between single-port (SP) extraperitoneal radical prostatectomy (EPRP) and SP transperitoneal radical prostatectomy (TPRP), in a multi-institutional setting. METHODS: We identified all patients who underwent SP robot-assisted radical prostatectomy at 6 different institutes. Data of 650 patients were collected and divided into 2 groups based on the surgical approach: SP EPRP or SP TPRP. A Propensity-score matched-pair analysis for body mass index (BMI), prostate size, and National Comprehensive Cancer Network risk was performed with a 1:1 ratio. Analysis of perioperative and postoperative outcomes was performed using Wilcoxon signed-rank test and chi-square and Fisher's exact tests. RESULTS: After matching, 238 patients were included in each arm. The median follow-up period was 7 and 6 months for EPRP and TPRP groups, respectively. The total operative time was longer in the EPRP group (206 vs 155 minutes, P < .001). The EPRP group had a shorter length of hospitalization and same-day discharge rate compared to the TPRP approach (P < .001). There was no difference in the overall intraoperative or postoperative complications rate between the 2 groups, nor positive surgical margin rates. CONCLUSION: The SP extraperitoneal approach is associated with a shorter hospital stay and higher rate of same-day discharge, with no difference in the surgical margin, or complication rates.

Single- versus multi-port robotic partial nephrectomy: a comparative analysis of perioperative outcomes and analgesic requirements.

Evidence supporting the safe use of the single-port (SP) robot for partial nephrectomy is scarce. The purpose of this study was to compare perioperative outcomes for patients undergoing robotic assisted SP vs multi-port (MP) partial nephrectomy (PN) in a time-matched cohort. All patients with clinically localized renal masses who underwent robotic PN from January 2019 to March 2020 were evaluated. Patients were stratified according to SP vs MP approach. Postoperative analgesia was administered in accordance with department-wide opioid stewardship protocol and outpatient opioid use was tracked. Total of 78 patients underwent robotic PN with 26 patients in the SP cohort. The majority of renal masses had low-complexity (53, 67.9%) R.E.N.A.L. nephrometry scores, without a significant difference between the two cohorts (p = 0.19). A retroperitoneal approach was performed in 16 (20.5%) patients overall, though more commonly via the SP robotic approach (13 vs 3, p < 0.001). Mean operative time for SP cases was 183.9 ± 63.5 min vs 208.6 ± 65.0 min in the MP cohort (p = 0.12). Rate of conversion to radical nephrectomy was 3.8% vs 9.6% for SP vs MP cases, respectively, (p = 0.37). The majority of patients were discharged on postoperative day one (67.9%) irrespective of operative approach (p = 0.60). There were no differences in inpatient milligram morphine equivalents administered (MME, p = 0.08) or outpatient postoperative MME prescribed (p = 0.21) between the two cohorts. In this retrospective single-institution study, SP robotic approach offers similar short-term perioperative outcomes to MP platforms for minimally invasive, nephron-sparing surgery. Using the SP system was not associated with a reduction in postoperative opioid analgesic requirements.

Stereotactic body radiation therapy with simultaneous integrated boost for prostate cancer: does MRI-targeted biopsy alter the boost field?

INTRODUCTION: We aim to investigate if the addition of MRI-US fusion biopsy (FB) can aid in radiation planning and alter the boost field in cases of stereotactic body radiation therapy (SBRT) for prostate cancer with a simultaneous integrated boost (SIB) to a magnetic resonance imaging (MRI)-defined intraprostatic lesion. MATERIALS AND METHODS: Patients undergoing SBRT with SIB for biopsy-proven prostatic adenocarcinoma and a pre-radiation MRI were retrospectively reviewed. 36.25 Gy in 5 fractions was delivered to entire prostate along with SIB of 40 Gy to an MRI-defined intraprostatic lesion. Demographic, radiation planning details, and post-procedural outcomes were compared between patients undergoing systematic transrectal ultrasound (TRUS) biopsy followed by MRI to those undergoing an MRI followed by a FB prior to radiation planning. RESULTS: Forty-three patients underwent systematic TRUS biopsy followed by MRI and 46 patients underwent FB prior to radiation planning. Patients undergoing systematic TRUS biopsy had a smaller prostate volume when compared to the FB cohort (37.58 ± 13.78 versus 50.28 ± 26.76 cc, p = 0.007). No differences in prostate planning target volume (PTVprostate) and boost volume (PTVboost) were noted, but those undergoing TRUS biopsy prior to MRI had a higher integrated boost volume density (IBVD = PTVboost/total prostate volume) (0.16 ± 0.09 versus 0.13 ± 0.06, p = 0.045). No differences were observed in genitourinary or gastrointestinal toxicity rates. CONCLUSIONS: Compared to systematic TRUS biopsy, implementation of prebiopsy prostate MRI and FB allows for safe and feasible SBRT in patients with significantly larger prostate volumes without increasing SIB cancer-directed treatment volumes, oncologic outcomes, quality of life measures, or treatment-related toxicities.

The stanford prostate cancer calculator: Development and external validation of online nomograms incorporating PIRADS scores to predict clinically significant prostate cancer.

BACKGROUND: While multiparametric MRI (mpMRI) has high sensitivity for detection of clinically significant prostate cancer (CSC), false positives and negatives remain common. Calculators that combine mpMRI with clinical variables can improve cancer risk assessment, while providing more accurate predictions for individual patients. We sought to create and externally validate nomograms incorporating Prostate Imaging Reporting and Data System (PIRADS) scores and clinical data to predict the presence of CSC in men of all biopsy backgrounds. METHODS: Data from 2125 men undergoing mpMRI and MR fusion biopsy from 2014 to 2018 at Stanford, Yale, and UAB were prospectively collected. Clinical data included age, race, PSA, biopsy status, PIRADS scores, and prostate volume. A nomogram predicting detection of CSC on targeted or systematic biopsy was created. RESULTS: Biopsy history, Prostate Specific Antigen (PSA) density, PIRADS score of 4 or 5, Caucasian race, and age were significant independent predictors. Our nomogram-the Stanford Prostate Cancer Calculator (SPCC)-combined these factors in a logistic regression to provide stronger predictive accuracy than PSA density or PIRADS alone. Validation of the SPCC using data from Yale and UAB yielded robust AUC values. CONCLUSIONS: The SPCC combines pre-biopsy mpMRI with clinical data to more accurately predict the probability of CSC in men of all biopsy backgrounds. The SPCC demonstrates strong external generalizability with successful validation in two separate institutions. The calculator is available as a free web-based tool that can direct real-time clinical decision-making.

Safety, Tolerability, and Long-Term Clinical Outcomes of an IL-15 analogue (N-803) Admixed with Bacillus Calmette-Guérin (BCG) for the Treatment of Bladder Cancer.

Intravesical BCG is active against non-muscle invasive bladder cancer (NMIBC), but bladder cancer will recur and even progress in a significant number of patients. To improve the response rate, N-803, an IL-15 superagonist was administered in combination with BCG. To evaluate the safety and efficacy associated with the use of intravesical N-803 and BCG in patients with BCG-naïve NMIBC. This phase 1b clinical trial used a 3 + 3 dose-escalation design. Participants were enrolled from July 2014 and July 2015, with follow-up and analyses through January 15, 2021. Eligibility criteria included histologically confirmed non-muscle invasive urothelial carcinoma of intermediate or high risk who had not received prior treatment with intravesical BCG (ie, BCG-naïve). All 9 participants met the eligibility criteria, received treatment according to the protocol, and were included in all analyses. Treatment was done once weekly for 6 consecutive weeks with bladder infusion of the standard dose of BCG, 50 mg/instillation, in combination with increasing doses of N-803 (100, 200, or 400 µg N-803 per instillation). No DLTs were noted in any of the dose cohorts. All adverse events (AEs) were manageable and less than grade 3. During the 2-year follow-up, all 9 participants were disease free. Furthermore, 6 y after treatment, all 9 participants (100%) were disease free with no evidence of disease progression and an intact bladder. This phase 1b trial found the combination of intravesical N-803 and BCG to be associated with modest toxic effects, low immunogenicity, and substantial prolonged antitumoral activity; phase 2 trials are in progress.

Portable Perfusion Phantom Offers Quantitative Dynamic Contrast-Enhanced Magnetic Resonance Imaging for Accurate Prostate Cancer Grade Stratification: A Pilot Study.

RATIONALE AND OBJECTIVES: The study goal was to test whether the improved accuracy in quantitative dynamic contrast-enhanced magnetic resonance imaging measurement using a point-of-care portable perfusion phantom (P4) leads to better stratification of prostate cancer grade. MATERIALS AND METHODS: A prospective clinical study was conducted recruiting 44 patients scheduled for multi-parameter MRI prostate exams. All participants were imaged with the P4 placed under their pelvic regions. Tissue sampling was carried out for 25 patients at 22 ± 18 (mean ± SD) days after multi-parameter MRI. On histologic examination, a total of 31 lesions were confirmed as prostate cancer. Tumors were classified into low grade (n = 14), intermediate grade (n = 10), and high grade (n = 7). Tumor perfusion was assessed by volume transfer constant, Ktrans, before and after P4-based error correction, and the Ktrans of low, intermediate and high-grade tumors were statistically compared. RESULTS: After P4-based error correction, the Ktrans of low, intermediate, and high-grade tumors were 0.109 ± 0.026 min-1 (95% CI: 0.0094 to 0.124 min-1), 0.163 ± 0.049 min-1 (95% CI: 0.129 to 0.198 min-1) and 0.356 ± 0.156 min-1 (95% CI: 0.215 to 0.495 min-1), respectively, with statistically significant difference among the groups (low vs intermediate: p = 0.002; intermediate vs high: p = 0.002; low vs high: p < 0.001). The sensitivity and specificity of Ktrans value, 0.14 min-1, to detect the clinically significant prostate cancer were 88% and 93%, respectively, after P4 based error correction, but those before error correction were 88% and 86%, respectively. CONCLUSION: The P4 allows to reduce errors in quantitative dynamic contrast-enhanced magnetic resonance imaging measurement, enhancing accuracy in stratification of prostate cancer grade.

Utility of 18F-Fluciclovine PET/MRI for Staging Newly Diagnosed High-Risk Prostate Cancer and Evaluating Response to Initial Androgen Deprivation Therapy: A Prospective Single-Arm Pilot Study.

BACKGROUND. Despite advances in prostate cancer treatment, rates of biochemical recurrence remain high, relating to lack of detection of small-volume metastatic disease using conventional imaging for initial staging. OBJECTIVE. The purpose of this study was to assess the potential use of 18F-fluciclovine PET/MRI for initial staging of high-risk prostate cancer and evaluating response to androgen deprivation therapy (ADT). METHODS. This prospective clinical trial enrolled 14 men with newly diagnosed high-risk prostate cancer and negative or equivocal conventional staging imaging for metastatic disease between January 2018 and February 2019. All patients underwent pretreatment 18F-fluciclovine PET/MRI including multiparametric prostate MRI; 12 underwent 18F-fluciclovine PET/MRI after surgery or between ADT and radiotherapy. Confidence in identification of the primary intraprostatic lesion and nodal metastases was independently rated on a 0-3 Likert scale by three readers with nuclear medicine experience for 18F-fluciclovine PET/MRI and three readers with abdominal imaging experience for MRI alone. Findings scored as 2 or 3 by at least two readers of a given modality were considered positive. A single reader measured SUVmean, SUVmax, and volume of the MRI-defined intraprostatic lesion and SUVmax of suspicious lymph nodes on PET before and after initiation of ADT. Changes in SUV were analyzed using nonparametric Wilcox-on signed-rank tests. RESULTS. The biopsy-proven lesion in the prostate gland was accurately identified in all 14 patients on both MRI and 18F-fluciclovine PET/MRI. Suspected nodal metastases were detected in three patients on MRI and seven patients on 18F-fluciclovine PET/MRI. After ADT, all patients showed decreased activity within the intraprostatic lesion and/or all suspicious lymph nodes. The primary lesion SUVmean was 4.5 ± 1.1 (range, 2.7-6.5) before treatment and 2.4 ± 1.1 (range, 0.0-3.6) after initiation of ADT (p = .008). For suspicious lymph nodes, the pretreatment SUVmax was 5.5 ± 3.7 (range, 2.8-12.7) and the post-treatment SUVmax was 2.8 ± 1.4 (range, 1.4-5.5) (p = .03). CONCLUSION.18F-labeled fluciclovine PET/MRI shows potential utility in initial staging of high-risk prostate cancer and in evaluating response to ADT. CLINICAL IMPACT. Given the FDA approval and widespread availability of 18F-fluciclovine, the findings could have an impact in the immediate future in guiding initial management of patients with prostate cancer. TRIAL REGISTRATION. ClinicalTrials.gov NCT03264456.

Synchronous Malignancies Identified by 18F-fluciclovine Positron Emission Tomography for Prostate Cancer: Case Series and Mini-Review.

Positron emission tomography using the fluorine-18 (18F) fluciclovine radiotracer has been approved for use in recurrent prostate cancer and is a useful tool for clinical decision making. However, 18F-fluciclovine is not specific for prostate cancer tumor cells, and false-positive results have been reported. In the present study, we have reported our experience with synchronous malignancies identified using 18F-fluciclovine and reviewed other reported cases, with a special emphasis on highlighting the clinical decisions that led to the correct diagnosis.

Renal Hilar Clamping With a Standard Robotic Bulldog Clamp Using the Single Port da Vinci Robot.

BACKGROUND: Renal hilar clamping during a robotic partial nephrectomy is essential for a successful, nephron-sparing tumor resection. Standard robotic bulldog clamps are modified to accommodate multiport robotic surgical systems with alterations including knobs to fit robotic forceps and reduced spring tension. Despite the lower spring tension, a standard robotic bulldog clamp cannot be loaded and opened using one Single Port robotic arm. The angled path instrument cables take through multiple robotic arm articulations lowers the maximum force generated by Single Port instruments to below what is necessary to load and open a robotic bulldog clamp. OBJECTIVE: To share institutional knowledge gained regarding safe and efficient hilar clamp placement and removal using the da Vinci Single Port Surgical System with a standard robotic bulldog clamp. As the da Vinci Single Port system gains wider use, knowledge of this technique will reduce surgeon trial-and-error during first experiences using the Single Port system with bulldog clamps. MATERIAL: Video obtained during two partial nephrectomies, da Vinci Single Port Surgical System, Scanlan Reliance 25 mm curved robotic bulldog clamp, Final Cut Pro video editing software. RESULTS: A controlled sequence of steps for renal hilar clamping and subsequent clamp removal using a standard robotic bulldog clamp with the da Vinci Single Port Surgical System. CONCLUSION: The demonstrated technique for intracorporeal loading, opening, and placement of a standard robotic bulldog clamp using the da Vinci Single Port Surgical System is feasible and efficient.

Single-port robotic partial and radical nephrectomies for renal cortical tumors: initial clinical experience.

To describe our institution's initial experience with radical (RN) and partial nephrectomy (PN) using the SP robotic system. The recent FDA approval of the da Vinci® SP robotic platform has led to its use in minimally invasive approaches to urologic malignancies. There are little data on its feasibility and safety after implementation for radical and partial nephrectomy. All patients who underwent PN or RN using the SP system at our institution were reviewed. All PNs were performed off-clamp. Patient demographics, preoperative imaging, operative approaches, and perioperative outcomes were collected and analyzed. Sixteen patients underwent PN (n = 13) or RN (n = 3) utilizing the SP robotic system between January 2019 and June 2019. Average age was 58.6 ± 13.9 and 61.0 ± 1.7 years in each group, respectively. A retroperitoneal approach was performed in 7 (53.8%) PN patients and 1 (33.3%) RN patient. A transperitoneal approach was performed in 6 (46.1%) PNs and 2 (66.7%) RNs. Mean operative time and median estimated blood loss for PN was 176.9 ± 64.0 min and 200 (50-800) ml compared to 176.3 ± 73.8 min and 50 (50-400) ml for RN. There was one operative conversion (7.7%) to an open approach in the PN group. Length of hospital stay postoperatively averaged 1.9 ± 1.3 days and 3.3 ± 1.2 days for patients undergoing partial and radical nephrectomy, respectively. SP partial and radical nephrectomies through transperitoneal and retroperitoneal approaches appear to be feasible surgical techniques in the management of cortical renal masses. Off-clamp PN is also a feasible approach using the SP system. However, further study is needed to establish its safety and use in renal surgery across multiple institutions and larger patient cohorts.

Perioperative Outcomes of Single vs Multi-Port Robotic Assisted Radical Prostatectomy: A Single Institutional Experience.

PURPOSE: Surgical approach to radical prostatectomy has evolved due to advances in minimally invasive surgery, with most contemporary approaches involving the Si or Xi multi-port robotic systems. U.S. Food and Drug Administration approval of the single-port da Vinci® SP robotic platform has led to a few case series suggesting its safety and feasibility for robotic assisted radical prostatectomy in patients with prostate cancer. However, there are no established data on perioperative outcomes comparing single-port to multi-port robotic approaches to robot-assisted radical prostatectomy. MATERIALS AND METHODS: All patients who underwent robot-assisted radical prostatectomy by 2 urological surgeons at our institution between October 2018 and June 2019 were retrospectively reviewed. The available preoperative clinical and demographic data, operative parameters and postoperative outcomes were collected and analyzed using the t-test, chi-square and Fisher exact statistical measures. RESULTS: Overall 95 patients who underwent robot-assisted radical prostatectomy at our institution were included in our study, with 47 single-port and 48 multi-port. Preoperative clinical parameters including age, body mass index, prior abdominal surgery and biopsy grade group were similar across the 2 groups. No differences in estimated blood loss (169.2±114.2 vs 157.7±125.4 ml, p=0.64), operative time (255.9±44.1 vs 274.7±50.4 minutes, p=0.06), length of hospitalization (1.1±0.5 vs 1.4±1.1 days, p=0.17), rate of perioperative inpatient Clavien-Dindo complications 2 or greater (4.3% vs 6.3% p=0.66) and rate of positive pathological margin (21.3% vs 27.1%, p=0.51) were noted comparing the single-port and multi-port approaches, respectively. CONCLUSIONS: The single-port robotic system allows a feasible approach to robot-assisted radical prostatectomy and has operative and perioperative outcomes comparable to those of the well accepted multi-port robotic approach.

Feasibility of Dose Escalating [18F]fluciclovine Positron Emission Tomography Positive Pelvic Lymph Nodes During Moderately Hypofractionated Radiation Therapy for High-Risk Prostate Cancer.

PURPOSE: The aim of this study was to report the treatment planning feasibility of dose escalation to suspicious lymph nodes (LNs) for a series of men who underwent pretreatment [18F]fluciclovine positron emission tomography (PET)/magnetic resonance imaging (MRI). METHODS AND MATERIALS: Cases of men with prostate cancer who enrolled in a clinical trial of pretreatment [18F]fluciclovine PET who had suspicious LNs were selected. Pelvic LNs <1 cm were defined as positive based on [18F]fluciclovine-PET if their maximum standardized uptake value (SUVmax) was ≥1.3-fold greater than the reference blood pool SUVmean, and LNs ≥1 cm were defined as positive if the SUV was greater than the reference SUV bone marrow reference. For each case, a radiation treatment plan was generated to deliver 70 Gy to the prostate and proximal seminal vesicles, 60.2 Gy to the PET-positive LNs, and 50.4 Gy to the elective nodal regions, simultaneously in 28 fractions of 2.5 Gy, 2.15 Gy, and 1.8 Gy, respectively. Treatment planning goals were defined a priori. The resulting target volume and organ-at-risk dosimetry were compared with the original treatment plan. RESULTS: Four cases were identified, with between 1 and 5 [18F]fluciclovine PET-positive LNs each. Goals for the prostate and elective nodal target volumes were successfully met in all cases. The goal of covering more than 90% of the positive LN planning target volume by the prescription dose of 60.2 Gy was met in 3 of the 4 cases. This goal was not met in 1 case, but 100% of clinical target volume was covered by 60.2 Gy. The primary organ-at-risk tradeoff was that a small volume (0.5-8.2 cm3) of small bowel would receive ≥54 Gy in each case. CONCLUSIONS: These preliminary results suggest that [18F]fluciclovine PET/MRI directed dose escalation of suspicious pelvic LNs is likely feasible in the setting of definitive radiation therapy. The potential clinical benefit of dose escalating [18F]fluciclovine PET-positive LNs should be investigated in a prospective clinical trial.

Self-Identified African Americans and prostate cancer risk: West African genetic ancestry is associated with prostate cancer diagnosis and with higher Gleason sum on biopsy.

Concerns about overtreatment of clinically indolent prostate cancer (PrCa) have led to recommendations that men who are diagnosed with low-risk PrCa be managed by active surveillance (AS) rather than immediate definitive treatment. However the risk of underestimating the aggressiveness of a patient's PrCa can be a significant source of anxiety and a barrier to patient acceptance of AS. The uncertainty is particularly keen for African American (AA) men who are about 1.7 times more likely to be diagnosed with PrCa than European American (EA) men and about 2.4 times more likely to die of this disease. The AA population, as many other populations in the Americas, is genetically heterogeneous with varying degrees of admixture from West Africans (WAs), Europeans, and Native Americans (NAs). Recommendations for PrCa screening and management rarely consider potential differences in risk within the AA population. We compared WA genetic ancestry in AA men undergoing standard prostate biopsy who were diagnosed with no cancer, low-grade PrCa (Gleason Sum 6), or higher grade PrCa (Gleason Sum 7-10). We found that WA genetic ancestry was significantly higher in men who were diagnosed with PrCa on biopsy, compared to men who were cancer-negative, and highest in men who were diagnosed with higher grade PrCa (Gleason Sum 7-10). Incorporating WA ancestry into the guidelines for making decisions about when to obtain a biopsy and whether to choose AS may allow AA men to personalize their approach to PrCa screening and management.

Evaluation of MSKCC Preprostatectomy nomogram in men who undergo MRI-targeted prostate biopsy prior to radical prostatectomy.

INTRODUCTION: The Memorial Sloan Kettering Cancer Center (MSKCC) Preprostatectomy nomogram is a widely used resource that integrates clinical factors to predict the likelihood of adverse pathology at radical prostatectomy. Adoption of magnetic resonance imaging targeted biopsy (TB) permits optimized detection of clinically-significant cancer over systematic biopsy (SB) alone. We aim to evaluate the prognostic utility of the MSKCC Preprostatectomy nomogram with TB pathology results. METHODS: Men who underwent SB and magnetic resonance imaging TB who later underwent radical prostatectomy at our institution were included. Patient information was entered into the MSKCC Preprostatectomy nomogram using 5 biopsy reporting schemes with TB reported by both individual core (IC) and aggregate group (AG) methods. The likelihood of extraprostatic extension, seminal vesicle invasion, and lymph node involvement as predicted by the nomogram for each biopsy reporting schema were compared to radical prostatectomy pathology. RESULTS: We identified 63 men from January 2014 to November 2017. On receiver operating characteristic analysis, IC-TB, AG-TB, SB plus IC-TB, and SB plus AG-TB exhibited similar, if not improved, area under the curve compared to SB alone in predicting extraprostatic extension (0.671, 0.674, 0.658, and 0.6613 vs. 0.6085). This was similarly observed for seminal vesicle invasion prediction using SB plus IC-TB compared to SB alone (0.727 vs. 0.733). For lymph node involvement, superior but nonsignificant area under the curve was observed for AG-TB (0.647) compared to IC-TB (0.571) and SB alone (0.524) CONCLUSIONS: Using TB pathology results either alone or combined with SB pathology results as input to the MSKCC Preprostatectomy nomogram appears comparable for prognosticating adverse pathology on radical prostatectomy compared to SB alone, but robust validation is warranted prior to adoption into clinical practice.