Simultaneous Retzius-sparing robot-assisted radical prostatectomy and partial nephrectomy.

We present a 61-year-old man who was diagnosed with synchronous prostate cancer and suspicious renal cell carcinoma of the right kidney, treated with combined Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and robot-assisted partial nephrectomy (RAPN). The combined approach using RS-RARP and RAPN is technically feasible and safe surgical option for treatment of concomitant prostate cancer and suspicious renal cell carcinoma.ope

Human and robot: an amity not a discord.

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Comparison of Trifecta and Pentafecta Outcomes between T1a and T1b Renal Masses following Robot-Assisted Partial Nephrectomy (RAPN) with Minimum One Year Follow Up: Can RAPN for T1b Renal Masses Be Feasible?

PURPOSE/OBJECTIVES: To investigate the feasibility of RAPN on T1b renal mass by assessment of Trifecta and Pentafecta rate between T1a and T1b renal mass. MATERIALS/METHODS: We retrospectively reviewed the medical records of 277 cases of RPN performed from 2006 to 2015. Sixty patients with clinically T1b renal masses (> 4 cm and ≤ 7 cm) were identified, and from 180 patients with clinically T1a renal mass, 60 patients were matched with T1b renal mass by propensity score. Tumor complexity was investigated according to R.E.N.A.L nephrometry score. "Pentafecta" was defined as achievement of Trifecta (negative surgical margin, no postoperative complications and warm ischemia time of ≤ 25 minutes) with addition of over 90% estimated GFR preservation and no chronic kidney disease stage upgrading at 1 year postoperative period. Propensity score matching was performed by OneToManyMTCH. Logistic regression models were used to identify the variables which predict the Trifecta, and Pentafecta ac. RESULTS: Preoperative variables (age, sex, body mass index, ASA score) were similar between T1a and T1b after propensity score matching. The median R.E.N.A.L. nephrometry score was 8 vs 9 for T1a and T1b respectively (p<0.001). The median warm ischemia time was 20.1 min vs 26.2 min (p<0.001). Positive surgical margin rate was 5% vs 6.6% (p = 0.729) and overall complication rate of 13.3%. vs 15% (p = 0.793). The rate of achievement of Trifecta rate were 65.3% vs 43.3% (p = 0.017) and Pentafecta rate were 38.3% vs 26.7% (p = 0.172). For achievement of Pentafecta, R.E.N.A.L nephrometry score (HR 0.80; 95% CI (0.67-0.97); p = 0.031) was significant predictor of achieving Pentafecta. Subanalyis to assess the component of R.E.N.A.L nephrometry score, L component (location relative to the polar lines, HR 0.63; 95% CI (0.38-1.03); P = 0.064) was relatively important component for Pentafecta achievement. CONCLUSIONS: The rate of Pentafecta after RAPN was comparable between T1a and T1b renal masses. RAPN is a feasible modality with excellent long term outcome for patients with larger renal mass (cT1b).ope

Single Positive Lymph Node Prostate Cancer Can Be Treated Surgically without Recurrence.

PURPOSE/OBJECTIVES: To investigate pN1 prostate cancer (PCa) patients treated surgically without immediate adjuvant treatment. MATERIALS AND METHODS: We analyzed the database of 2316 patients at our institution who underwent robot-assisted radical prostatectomy (RARP)/radical prostatectomy (RP) between July 2005 and November 2012. 87 patients with pN1 PCa and received no neoadjuvant and immediate adjuvant therapy were included in the study. Included pN1 PCa patients were followed up for median of 60 months. Biochemical recurrence (BCR)-free survival, metastasis-free survival (MFS), cancer specific survival (CSS), and overall survival (OS) rates were determined by using Kaplan-Meier analysis. Cox regression analysis was performed to investigate the impact of prostate-specific antigen (PSA) level, Gleason score, extraprostatic extension, seminal vesicle invasion, perineural invasion, lymphovascular invasion, positive surgical margin, tumor volume, early post-operative PSA(6 weeks), PSA nadir, lymph node yield, and number of pathologically positive lymph nodes on survival. RESULTS: The 5-year OS rate of patients was 86.1%, while the CSS rate was 89.6%. The metastasis-free and BCR-free survival rates were 71% and 19.1%, respectively, and each was significantly correlated with the number of positive lymph nodes on log rank tests (p = 0.004 and p = 0.039, respectively). The presence of 2 or more pathologically positive LNs (HR:2.20; 95% CI 1.30-3.72; p = 0.003) and a Gleason score ≥8 (HR: 2.40;95% CI: 1.32-4.38; p = 0.04) were significant negative predictors of BCR free survival on multivariable regression analysis. Furthermore, the presence of 2 or more positive lymph nodes (HR: 1.06; 95% CI 1.01-1.11; p = 0.029) were significant negative predictors of metastasis-free survival on multivariable regression analysis. Additionally, in the patients who had no BCR without adjuvant treatment 9 patients out of 10 (90%) had single positive LN and 5 patients out of 10 (50%) had Gleason score 7. Therefore, single positive LN, and Gleason scores ≤7 have significantly low risk of disease progression. CONCLUSIONS: pN1 PCa patients have heterogenous clinical courses. Patients with single positive LN, and Gleason scores ≤7 have low risk of recurrence. Close observation with delayed adjuvant hormone therapy can be considered in these patients.ope

Proctorship and mentoring: Its backbone and application in robotic surgery

In pursuit of continuing medical education in robotic surgery, several forms of training have been implemented. This variable application of curriculum has brought acquisition of skills in a heterogeneous and unstandardized fashion from different parts of the world. Recently, efforts have been made to provide cost effective and well-structured curricula with the aim of bridging the gap between formal fellowship training and short courses. Proctorship training has been implicated on some curriculum to provide excellent progression during the learning curve while ensuring patient safetyope

Prostate-specific antigen 10-20 ng/mL: A predictor of degree of upgrading to ≥8 among patients with biopsy Gleason score 6

PURPOSE: This study aimed to identify the predictors of upgrading and degree of upgrading among patients who have initial Gleason score (GS) 6 treated with robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: A retrospective review of the data of 359 men with an initial biopsy GS 6, localized prostate cancer who underwent RARP between July 2005 to June 2010 was performed. They were grouped into group 1 (nonupgrade) and group 2 (upgraded) based on their prostatectomy specimen GS. Logistic regression analysis of studied cases identified significant predictors of upgrading and the degree of upgrading after RARP. RESULTS: The mean age and prostate-specific antigen (PSA) was 63±7.5 years, 8.9±8.77 ng/mL, respectively. Median follow-up was 59 months (interquartile range, 47-70 months). On multivariable analysis, age, PSA, PSA density and ≥2 cores positive were predictors of upgrading with (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.06; p=0.003; OR, 1.006; 95% CI, 1.01-1.11; p=0.018; OR, 0.65; 95% CI, 0.43-0.98, p=0.04), respectively. On subanalysis, only PSA level of 10-20 ng/mL is associated with upgrading into GS ≥8. They also had lower biochemical recurrence free survival, cancer specific survival, and overall survival (p≤0.001, p=0.003, and p=0.01, respectively). CONCLUSIONS: Gleason score 6 patients with PSA (10-20 ng/mL) have an increased risk of upgrading to pathologic GS (≥8), subsequently poorer oncological outcome thus require a stricter follow-up. These patients should be carefully counseled in making an optimal treatment decision.ope

Re: Robotic Partial Nephrectomy in the Treatment of Renal Angiomyolipomas (From: Kara O, Akca O, Zagar H, et al. J Endourol 2016;30:275-279).

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Partial versus radical nephrectomy in very elderly patients: a propensity score analysis of surgical, functional and oncologic outcomes (RESURGE project)

Purpose To compare the outcomes of PN to those of RN in very elderly patients treated for clinically localized renal tumor. Patients and methods A purpose-built multi-institutional international database (RESURGE project) was used for this retrospective analysis. Patients over 75 years old and surgically treated for a suspicious of localized renal with either PN or RN were included in this database. Surgical, renal function and oncological outcomes were analyzed. Propensity scores for the predicted probability to receive PN in each patient were estimated by logistic regression models. Cox proportional hazard models were estimated to determine the relative change in hazard associated with PN vs RN on overall mortality (OM), cancer-specific mortality (CSM) and other-cause mortality (OCM). Results A total of 613 patients who underwent RN were successfully matched with 613 controls who underwent PN. Higher overall complication rate was recorded in the PN group (33% vs 25%; p = 0.01). Median follow-up for the entire cohort was 35 months (interquartile range [IQR] 13-63 months). There was a significant difference between RN and PN in median decline of eGFR (39% vs 17%; p < 0.01). PN was not correlated with OM (HR = 0.71; p = 0.56), OCM (HR = 0.74; p = 0.5), and showed a protective trend for CSM (HR = 0.19; p = 0.05). PN was found to be a protective factor for surgical CKD (HR = 0.28; p < 0.01) and worsening of eGFR in patients with baseline CKD. Retrospective design represents a limitation of this analysis. Conclusions Adoption of PN in very elderly patients with localized renal tumor does not compromise oncological outcomes, and it allows better functional preservation at mid-term (3-year) follow-up, relative to RN. Whether this functional benefit translates into a survival benefit remains to be determined.restrictio

Robot-assisted partial nephrectomy confers excellent long-term outcomes for the treatment of complex cystic renal tumors: Median follow up of 58 months

OBJECTIVES: To analyze long-term outcomes of robot-assisted partial nephrectomy for treatment of complex cystic renal tumors. METHODS: We retrospectively analyzed the data of patients who underwent robot-assisted partial nephrectomy for cystic (n = 32) and solid (n = 263) renal masses at Severance Hospital, Seoul, Korea. The primary outcome was assessment of perioperative safety for cystic tumor. Secondary outcomes were evaluation of long-term oncological and functional results. RESULTS: Patients' clinical and demographic characteristics were similar among both groups. The median follow up of cystic and solid masses were 58 and 46 months, respectively. Cystic masses were more likely to have low Fuhrman grade 1 and 2 (P = 0.03), and shorter operative time (P = 0.04) compared with solid masses. There was no statistically significant difference regarding warm ischemia time, estimated blood loss, trifecta achievement, length of hospital stay, complication rates and renal function preservation (P > 0.05) between groups. In the solid group, 12 patients (4.1%) recurred, and six patients (2%) died from metastatic renal cell carcinoma, whereas the patients in the cystic group did not have any local or distance recurrence, and the survival rates were 100%. The 5-year cancer-free survival (P = 0.77), cancer-specific survival (P = 0.65) and overall survival (P = 0.83) rates were similar between the groups. CONCLUSION: Robot-assisted partial nephrectomy appears to be safe and feasible treatment for complex cystic renal masses. It confers excellent long-term oncological outcomes. Robot-assisted partial nephrectomy should be the treatment of choice for complex cysts whenever feasible.restrictio

Novel robotic systems and future directions

Robot-assistance is increasingly used in surgical practice. We performed a nonsystematic literature review using PubMed/MEDLINE and Google for robotic surgical systems and compiled information on their current status. We also used this information to predict future about the direction of robotic systems based on various robotic systems currently being developed. Currently, various modifications are being made in the consoles, robotic arms, cameras, handles and instruments, and other specific functions (haptic feedback and eye tracking) that make up the robotic surgery system. In addition, research for automated surgery is actively being carried out. The development of future robots will be directed to decrease the number of incisions and improve precision. With the advent of artificial intelligence, a more practical form of robotic surgery system can be introduced and will ultimately lead to the development of automated robotic surgery system.ope