Intraoperative complications (ICs) are invariably underreported in urological surgery despite the recent endorsement of new classification systems. We aimed to provide a detailed overview of ICs ...during Retzius-sparing robot-assisted radical prostatectomy (RS-RARP).
We prospectively collected data from 1891 patients who underwent RS-RARP at a single high-volume European center from January 2010 to December 2022. ICs were collected based on surgery reports and categorized according to the Intraoperative Adverse Incident Classification (EAUiaiC). The quality criteria for accurate and comprehensive reporting of intraoperative adverse events proposed by the Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration Project were fulfilled. To better classify the role of the RS-RARP approach, ICs were classified into anesthesiologic and surgical ICs. Surgical ICs were further divided according to the timing of the complication in RARP-related ICs and ePNLD-related ICs.
Overall, 40 ICs were reported in 40 patients (2.1%). Ten out of thirteen ICARUS criteria were satisfied. According to EAUiaiC grading of ICs, 27 (67.5%), 7 (17.5%), 2 (5%), 2 (5%), and 2 (5%) patients experienced Grade 1, 2, 3, 4A, and 4B, respectively. When we classified the ICs, two cases (5%) were classified as anesthesiologic ICs. Among the 38 surgical ICs, 16 (42%) were ePNLD-related, and 22 (58%) were RARP-related. ICs led to seven (0.37%) post-operative sequelae (four non-permanent and three permanent). Patients who suffered ICs were significantly older (67 years vs. 65 years,
= 0.02) and had a higher median BMI (27.0 vs. 26.1,
= 0.01), but did not differ in terms of comorbidities or tumor characteristics (all
values ≥ 0.05).
Intraoperative complications during RS-RARP are relatively infrequent, but should not be underestimated. Patients suffering from ICs are older, have a higher body mass index, a higher rate of intraoperative blood transfusion, and a longer length of stay.
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Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) allows the preservation of the structures advocated to play a crucial role in the continence mechanism. This study aims to evaluate the ...association between adjuvant radiation therapy (aRT) and urinary continence (UC) recovery after RS-RARP. For the purpose of the current study, all patients submitted to RS-RARP for prostate cancer (PCa) at a single high-volume European institution between January 2010 and December 2021 were identified. Only patients that harbored pT2 stage with positive surgical margins or pT3/pN1 stage with or without positive surgical margins were included in the analyses. Two groups of patients were identified as follows: patients who had undergone aRT and patients submitted to observation (no-aRT patients). As per definition, aRT was delivered within 1–6 months after surgery. After 1:1 propensity score matching, 124 aRT patients were compared with 124 no-aRT patients who continued standard follow-up protocol after surgery. UC recovery was 81 vs. 84% in aRT vs. no-aRT patients (p = 0.7). In multivariable Cox regression analyses, aRT did not reach the independent predictor status for UC recovery at 12 months. In the subgroup analysis including only aRT patients, only the nerve-sparing technique was independently associated with UC recovery at 12 months. Conversely, the type of aRT (IMRT/VMAT vs. 3D-CRT) did not reach the independent predictor status for UC recovery at 12 months. The current study is the first to address the association between aRT and UC recovery in patients treated with RS-RARP for PCa. Based on our data, aRT is not associated with worse UC recovery. In the cohort of patients treated with aRT, the nerve-sparing technique independently predicted UC recovery.
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Within the Surveillance, Epidemiology, and End Results database (2000-2019), we identified 5522 unilateral surgically treated non-metastatic chromophobe kidney cancer (chRCC) patients. This ...population was randomly divided into development vs. external validation cohorts. In the development cohort, the original Leibovich 2018 and GRANT categories were applied to predict 5- and 10-year cancer-specific survival (CSS). Subsequently, a novel multivariable nomogram was developed. Accuracy, calibration and decision curve analyses (DCA) tested the Cox regression-based nomogram as well as the Leibovich 2018 and GRANT risk categories in the external validation cohort. The accuracy of the Leibovich 2018 and GRANT models was 0.65 and 0.64 at ten years, respectively. The novel prognostic nomogram had an accuracy of 0.78 at ten years. All models exhibited good calibration. In DCA, Leibovich 2018 outperformed the novel nomogram within selected ranges of threshold probabilities at ten years. Conversely, the novel nomogram outperformed Leibovich 2018 for other values of threshold probabilities. In summary, Leibovich 2018 and GRANT risk categories exhibited borderline low accuracy in predicting CSS in North American non-metastatic chRCC patients. Conversely, the novel nomogram exhibited higher accuracy. However, in DCA, all examined models exhibited limitations within specific threshold probability intervals. In consequence, all three examined models provide individual predictions that might be suboptimal and be affected by limitations determined by the natural history of chRCC, where few deaths occur within ten years from surgery. Further investigations regarding established and novel predictors of CSS and relying on large sample sizes with longer follow-up are needed to better stratify CSS in chRCC.
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4.
Editorial Comment Galfano, Antonio; Tappero, Stefano
The Journal of urology,
03/2021, Volume:
205, Issue:
3
Journal Article
We aimed at assessing the impact of non-urothelial variant histology (VH), relative to urothelial carcinoma of the urinary bladder (UCUB), on cancer-specific mortality (CSM) in T2N0M0 bladder cancer ...patients treated with trimodal therapy (TMT). TMT patients treated for T2N0M0 bladder cancer were identified within the Surveillance, Epidemiology, and End Results database (2000−2018). Patients who underwent TMT received trans-urethral resection of the bladder tumor, chemotherapy, and radiotherapy. CSM-FS rates were tested using Kaplan−Meier plots and multivariable Cox-regression (MCR) models according to histological subtype: UCUB vs. neuroendocrine carcinoma vs. squamous cell carcinoma vs. adenocarcinoma. A total of 3846 T2N0MO bladder cancer patients treated with TMT were identified. Of these, 3627 (94.3%) harbored UCUB, while 105 (2.7%), 85 (2.2%), and 29 (0.8%) harbored neuroendocrine carcinoma, squamous cell carcinoma, and adenocarcinoma, respectively. In Kaplan−Meier analyses, 3-yr CSM-FS rates were 57% for UCUB, 51% for neuroendocrine carcinoma, 35% for squamous cell carcinoma, and 60% for adenocarcinoma (p-value < 0.0001). In MCR models, only squamous cell carcinoma exhibited higher CSM than UCUB (HR 1.98, 95%CI 1.5−2.61, p-value < 0.001). Despite the small number of observations, squamous cell carcinoma distinguished itself from UCUB based on worse survival in T2N0M0 patients after TMT.
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To describe operatory room (OR) setting, trocar placement, surgical technique and perioperative outcomes of retroperitoneal (rRAPN) and transperitoneal (tRAPN) robot-assisted partial nephrectomy with ...the Hugo™ robot-assisted surgical (RAS) system.
We present our prospective, series of the first ten consecutive patients submitted to either rRAPN or tRAPN with the Hugo™ RAS system (Medtronic, Minneapolis, MN, USA) at ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy, between April 2023 and June 2023. The outcomes of interest were to describe the OR setting, trocar placement and the performance of this novel robotic system. Pre, intra and post-operative variables were recorded. A descriptive analysis was performed.
Overall, ten patients underwent RAPN with the Hugo™ RAS system, of which two were rRAPN (one left and one right renal mass) and eight tRAPN (two left, five right, one bilateral). Median (interquartile range, IQR) tumor size was 2.75 cm, with a median PADUA score of 7 (7,9). Median time from first trocar placement to console was 20 (15, 23) minutes, median console time was 136 (100, 159) minutes, and median operative time was 185 (170, 232) minutes. No intra-operative complications were recorded. Four post-operative complications were reported: one patient developed acute kidney injury (AKI, Clavien-Dindo 1), one patient required a longer hospital stay due to chylous production from the drain after hilar lymphadenectomy (Clavien-Dindo 2) and two pneumothoraxes (Clavien-Dindo 3a). Median (IQR) hospital stay was 5 (3,7) days. At final pathology, clear cell RCC, papillary RCC, chromophobe RCC and oncocytoma were found in respectively seven (70 %), one (10 %), one (10 %), and one (10 %) patients, with T1a, T1b and T3a (perirenal fat invasion) stages in six (60 %), three (30 %) and one (10 %) patients, respectively.
This video article illustrates the steps of both rRAPN and tRAPN with the Hugo™ RAS system. Our preliminary results demonstrate that both rRAPN and tRAPN are feasible with this novel robotic platform. Future large case series with long-term follow-up are needed to understand whether Hugo™ RAS system represents a true alternative to Intuitive platforms for nephron-sparing surgery.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Robot-assisted radical prostatectomy (RARP) with a Retzius-sparing approach is safe also in high-risk prostate cancer patients. It represents a valid alternative to standard RARP, allowing optimal ...cancer control and functional outcomes.
Retzius-sparing (RS) robot-assisted radical prostatectomy represents a valid surgical treatment option for prostate cancer (PCa) patients. However, the available evidence on the role of RS in high-risk (HR) PCa setting is sparse.
To describe our RS technique for HR-PCa patients and to evaluate intra-, peri-, and postoperative oncological and functional outcomes.
A total of 340 D’Amico HR-PCa patients underwent RS at a single high-volume centre between 2011 and 2020.
Surgical procedures were performed by five experienced robotic surgeons.
Complications were collected according to the standardised methodology proposed by the European Association of Urology guidelines. Postoperative outcomes were evaluated in patients with complete follow-up data (n = 320). Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values of ≥0.2 ng/ml. Urinary continence (UC) recovery was defined as the use of zero or one safety pad. Kaplan-Meier and multivariable logistic and Cox regression models were performed.
Fourteen patients (4%) experienced intraoperative complications and 52 90-d complications occurred in 44 patients (14%), of whom 24 had Clavien-Dindo 3a/b. Final pathology reported 49% International Society of Urological Pathology (ISUP) grade 4–5, 55% ≥pT3a, and 28.8% positive surgical margins (PSMs; 9.4% focal and 19.4% extended PSMs). The median follow-up was 47 mo. Overall, 35.3% and 1.3% harboured BCR and died from PCa. At 4 yr of follow-up, BCR-free survival and additional treatment-free survival were 63.6% and 56.6%, respectively. ISUP 4–5 at biopsy (odds ratio OR: 2.6), prostate volume (OR: 1.03), partial or full nerve sparing (OR: 1.9), and full bladder neck preservation (OR: 2.2) were independent predictors of PSMs. Pathological ISUP 4–5 (hazard ratio HR: 1.5) and PSMs (HR: 2.3) were independent predictors of BCR. Pathological ISUP 4–5 (HR: 1.5), PSMs (HR: 2.4), pT ≥3b (HR: 1.8), and pN ≥1 (HR: 1.8) were independent predictors of additional treatment. Immediate UC recovery was recorded in 53% patients. The 1- and 2-yr UC recovery and erectile function recovery were, respectively, 84% and 85%, and 43% and 50%.
RS in HR-PCa patients allows optimal intra-, peri-, and postoperative outcomes. The RS approach should be considered a valid surgical treatment option for HR-PCa patients in expert hands.
Relying on the largest cohort of high-risk prostate cancer patients treated with Retzius sparing (RS), we observed that the RS approach is safe and allows optimal cancer control, without significantly compromising functional outcomes.
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We aimed to test for survival differences between testicular pure teratoma vs. mixed germ cell tumor (GCT) patients in a stage-specific fashion. Pure teratoma and mixed GCT in primary tumor specimens ...were identified within the Surveillance, Epidemiology, and End Results database (2004-2019). Kaplan-Meier curves depicted five-year overall survival (OS) and subsequently, cumulative incidence plots depicted cancer-specific mortality (CSM) and other-cause mortality (OCM) in a stage-specific fashion. Multivariable competing risks regression (CRR) models were used. Of 9049 patients, 299 (3%) had pure teratoma. In stage I, II and III, five-year OS rates differed between pure teratoma and mixed GCT (stage I: 91.6 vs. 97.2%,
< 0.001; stage II: 100 vs. 95.9%,
< 0.001; stage III: 66.8 vs. 77.8%,
= 0.021). In stage I, survival differences originated from higher OCM (6.4 vs. 1.2%;
< 0.001). Conversely in stage III, survival differences originated from higher CSM (29.4 vs. 19.0%;
= 0.03). In multivariable CRR models, pure teratoma was associated with higher OCM in stage I (Hazard Ratio (HR): 4.83;
< 0.01). Conversely, in stage III, in multivariable CRR models, pure teratoma was associated with higher CSM (HR: 1.92;
= 0.04). In pure teratoma, survival disadvantage in stage I patients relates to OCM. Survival disadvantage in stage III pure teratoma originates from higher CSM.
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: The impact of pure histological subtypes in testicular non-seminoma germ cell tumors on survival, specifically regarding pure embryonal carcinoma, is not well established. Therefore, this study ...aimed to test for differences between pure embryonal carcinoma and mixed germ cell tumor patients within stages I, II and III in a large population-based database.
: We relied on the Surveillance, Epidemiology and End Results (SEER) database (2004-2019) to identify testicular pure embryonal carcinoma vs. mixed germ cell tumor patients. Cumulative incidence plots depicted cancer-specific mortality that represented the main endpoint of interest. Multivariable competing risks regression models tested for differences between pure embryonal carcinoma and mixed germ cell tumor patients in analyses addressing cancer-specific mortality and adjusted for other-cause mortality.
: Of 11,223 patients, 2473 (22%) had pure embryonal carcinoma. Pure embryonal carcinoma patients exhibited lower cancer-specific mortality relative to their mixed germ cell tumor counterparts for both stage III (13.9 vs. 19.4%;
< 0.01) and stage II (0.5 vs. 3.4%,
< 0.01), but not in stage I (0.9 vs. 1.6%,
= 0.1). In multivariable competing risks regression models, pure embryonal carcinoma exhibited more favorable cancer-specific mortality than mixed germ cell tumor in stage III (hazard ratio 0.71,
= 0.01) and stage II (hazard ratio 0.11,
< 0.01).
: Pure embryonal carcinoma exhibits a more favorable cancer-specific mortality profile relative to mixed germ cell tumor in stage II and III testicular cancers. Consequently, the presence of mixed germ cell tumor elements may be interpreted as a risk factor for cancer-specific survival.
In the specific setting of robot-assisted radical cystectomy, ileal conduit, relative to orthotopic neobladder, is associated with lower operative time and length of stay. Furthermore, ileal conduit ...provides a protective effect in terms of postoperative urinary diversion–related complications.
Head-to-head comparisons between ileal conduit (IC) and orthotopic neobladder (ONB) in terms of peri- and postoperative outcomes and complications, in the specific setting of robot-assisted radical cystectomy (RARC), are not available.
To address the impact of the type of urinary diversion (UD, IC vs ONB) on RARC morbidity, as well as operative time (OT), length of stay (LOS), and readmissions.
Urothelial bladder cancer patients treated with RARC at nine high-volume European institutions between 2008 and 2020 were identified.
RARC with either IC or ONB.
Intra- and postoperative complications were collected and reported according to the Intraoperative Complications Assessment and Reporting with Universal Standards recommendations and European Association of Urology guidelines, respectively. Multivariable logistic regression models tested the impact of UD on outcomes, after adjustment for clustering at single hospital level.
Overall, 555 nonmetastatic RARC patients were identified. In 280 (51%) and 275 (49%) patients, an IC and an ONB were performed, respectively. Eighteen intraoperative complications were recorded. The rates of intraoperative complications were 4% in IC patients and 3% in ONB patients (p = 0.4). The median LOS and readmission rates were 10 versus 12 d (p < 0.001) and 20% versus 21% (p = 0.8) in IC versus ONB patients, respectively. At a multivariable logistic regression analyses, the type of UD (IC vs ONB) reached the independent predictor status for prolonged OT (odds ratio OR: 0.61, p = 0.03) and prolonged LOS (OR: 0.34, p < 0.001), but not for readmission (OR: 0.92, p = 0.7). Overall, 513 postoperative complications were experienced by 324 patients (58%). At least one postoperative complication was experienced by 160 (57%) IC patients versus 164 (60%) ONB patients (p = 0.6). The type of UD reached the status of an independent predictor of UD-related complications (OR: 0.64, p = 0.03).
Compared with RARC with ONB, RARC with IC is less prone to UD-related postoperative complications, prolonged OT, and prolonged LOS.
To date, the impact of the type of urinary diversion, namely, ileal conduit versus orthotopic neobladder, on peri- and postoperative outcomes of robot-assisted radical cystectomy is unknown. Based on a rigorous data accrual, which relied on established complication reporting systems (Intraoperative Complications Assessment and Reporting with Universal Standards and European Association of Urology recommended systems), we reported intra- and postoperative complications according to urinary diversion type. Moreover, we found that ileal conduit was associated with lower operative time and length of stay, and yielded a protective effect in terms of urinary diversion–related complications.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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