Robot-assisted segmental ureterectomy with psoas hitch ureteral reimplantation: Oncological, functional and perioperative outcomes of case series of a single centre.

Introduction: According to the Urology guidelines, in selected cases of distal upper tract urothelial carcinoma (UTUC) segmental ureterectomy (SU) can be offered. There is no consensus in the surgical technique of preference. Robot-assisted SU could be an option to overcome all the limitations of open and laparoscopic techniques. We describe our first experience of robot assisted SU with psoas hitch ureteral reimplantation (RAPHUR). Materials and methods: 11 patients underwent RAPHUR for distal UTUC between 2013 and 2017 in a single centre. Pre-, intra-, and postoperative outcomes were assessed. Conventional imaging was performed after 1, 3, 6 months and 1 year from surgery as follow up protocol. We retrospectively evaluated the technical feasibility, oncological and functional outcomes. Results: Median age was 71 years (57-91). The median length of the ureteral defect was 23 mm (10-40). Median preoperative creatinine level was 1.22 mg/dl (0.7-1.85) and median eGFR was 57.5 ml/min/1.73m2 (31-80). Five (45.5%) patients were symptomatic and 7 (63.6%) had hydronephrosis. Median operative time was 185 min (120-240), with a median blood loss of 100 ml (50-300). No case required conversion to open surgery. Overall, only 1 (9%) patient developed Clavien Dindo ≥ 3 postoperative complications. Average hospital stay was 7 (2-9) days. Mean postoperative creatinine was 1.05 mg/dl (0.8-1.85) and mean postoperative eGFR was 72 (36-83). During a median follow up time of 25.5 months (12-53), 4 (36.4%) patients experienced recurrence of urothelial cancer at conventional imaging follow up and 2 (18.2%) died due to its progression. Conclusions: In our initial experience RAPHUR can be proposed to selected cases of distal ureteral carcinoma with optimal perioperative and functional outcomes. However, cancer control may be undermined compared to nephroureterectomy. Thus, further prospective studies are needed to confirm our findings

Robot-geassisteerde nefro-ureterectomie voor urotheelCa van de hogere urinewegen : resultaten van 3 high-volume robot centra

Doelstelling: Robot-geassisteerde nefro-ureterectomie (RANU) vormt een minimaal invasief alternatief voor open nefro-ureterectomie in de behandeling van urotheelcelcarcinoom van de hogere urinewegen (UTUC). Het doel van deze studie is om de perioperatieve en oncologische uitkomst na RANU te onderzoeken. Materiaal en Methoden: Tussen 2008 en 2017 ondergingen 78 patiënten RANU voor UTUC in 3 high-volume robot centra. Retrospectieve analyse met beschrijvende statistiek en Kaplan-Meier curves gebeurde om de intra- en postoperatieve complicaties te beschrijven, en de oncologische uitkomst (algeheel en gestratifieerd volgens hervaltype en pathologisch tumorstadium) te onderzoeken. Resultaten: De mediane leeftijd bij diagnose was 72jaar (IQR 65-78) met een mediane Charlson comorbidity index van 3 (IQR 1-6). Man-vrouw ratio was 2:1. De tumor bevond zich ter hoogte van het renaal/pyelo-calicieel systeem (52%), de proximale ureter (6%), midureteraal (19%), de distale ureter (2%) of multifocaal (21%). Het mediane geschatte bloedverlies was 75ml (IQR 35-180) en de mediane verblijfsduur 4dagen (IQR 4-6). Bloedtransfusies gebeurden bij 3% van de patiënten. Intraoperatieve complicaties traden op in 5% en postoperatieve complicaties in 25% van de gevallen. Clavien-Dindo graad ≥ III complicaties traden op bij 3%. Pathologisch tumorstadium betrof pTa (27%), pTis (3%), pT1 (21%), pT2 (17%), pT3 (24%), pT4 (5%) of pT0 (3%). Lymfeklierdissectie gebeurde bij 31 patiënten (40%) waarvan er bij 29% lymfeklieren waren betrokken. Bij een mediane opvolgingstijd van 15 maanden, is de geschatte algehele 2jaarsoverleving 79%. Gestratifieerd volgens hervaltype is dit respectievelijk 100% voor blaasherval en 16% voor patiënten met herval op afstand (p<0.001). Gestratifieerd volgens pT-stadium is dit 95%, 90% en 41% voor respectievelijk pTa-1, pT2 en pT3-4 tumoren (p=0.01). Peritoneale metastasering werd gezien bij 1 patiënt met pT4N2R1 UTUC. Conclusie: RANU is een veilige en doenbare chirurgische strategie als minimaal invasieve behandeling voor patiënten met UTUC. Postoperatieve morbiditeit is accepteerbaar en het aantal zware complicaties is zeer laag. Op korte termijn lijkt de oncologische uitkomst zeker aanvaardbaar zonder dat er aanwijzingen zijn op een verhoogd risico op peritoneale metastasering

Morbidity and mortality after robot-assisted radical cystectomy with intracorporeal urinary diversion in octogenarians: results from the European Association of Urology Robotic Urology Section Scientific Working Group

OBJECTIVES: To evaluate the postoperative complication and mortality rate following laparoscopic radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in octogenarians. PATIENTS AND METHODS: We conducted a retrospective analysis comparing postoperative complication and mortality rates depending on age in a consecutive series of 1890 patients who underwent RARC with ICUD for bladder cancer between 2004 and 2018 in 10 European centres. Outcomes of patients aged <80 years and those aged ≥80 years were compared with regard to postoperative complications (Clavien–Dindo grading) and mortality rate. Cancer-specific mortality (CSM) and other-cause mortality (OCM) after surgery were calculated using the non-parametric Aalen-Johansen estimator. RESULTS: A total of 1726 patients aged <80 years and 164 aged ≥80 years were included in the analysis. The 30- and 90-day rate for high-grade (Clavien–Dindo grades III–V) complications were 15% and 21% for patients aged <80 years compared to 11% and 13% for patients aged ≥80 years (P = 0.2 and P = 0.03), respectively. In a multivariable logistic regression analysis adjusting for pre- and postoperative variables, age ≥80 years was not an independent predictor of high-grade complications (odds ratio 0.6, 95% confidence interval 0.3–1.1; P = 0.12). The non-cancer-related 90-day mortality was 2.3% for patients aged ≥80 years and 1.8% for those aged <80 years, respectively (P = 0.7). The estimated 12-month CSM and OCM rates for those aged <80 years were 8% and 3%, and for those aged ≥80 years, 15% and 8%, respectively (P = 0.009 and P < 0.001). CONCLUSIONS: The minimally invasive approach to RARC with ICUD for bladder cancer in well-selected elderly patients (aged ≥80 years) achieved a tolerable high-grade complication rate; the 90-day postoperative mortality rate was driven by cancer progression and the non-cancer-related rate was equivalent to that of patients aged <80 years. However, an increased OCM rate in this elderly group after the first year should be taken into account. These results will support clinicians and patients when balancing cancer-related vs treatment-related risks and benefits

Definition of a Structured Training Curriculum for Robot-assisted Radical Cystectomy with Intracorporeal Ileal Conduit in Male Patients: A Delphi Consensus Study Led by the ERUS Educational Board

Robot-assisted radical cystectomy (RARC) continues to expand, and several surgeons start training for this complex procedure. This calls for the development of a structured training program, with the aim to improve patient safety during RARC learning curve. A modified Delphi consensus process was started to develop the curriculum structure. An online survey based on the available evidence was delivered to a panel of 28 experts in the field of RARC, selected according to surgical and research experience, and expertise in running training courses. Consensus was defined as ≥80% agreement between the responders. Overall, 96.4% experts completed the survey. The structure of the RARC curriculum was defined as follows: (1) theoretical training; (2) preclinical simulation-based training: 5-d simulation-based activity, using models with increasing complexity (ie, virtual reality, and dry- and wet-laboratory exercises), and nontechnical skills training session; (3) clinical training: modular console activity of at least 6 mo at the host center (a RARC case was divided into 11 steps and steps of similar complexity were grouped into five modules); and (4) final evaluation: blind review of a video-recorded RARC case. This structured training pathway will guide a starting surgeon from the first steps of RARC toward independent completion of a full procedure. Clinical implementation is urgently needed

Different approaches for bladder neck dissection during robot-assisted radical prostatectomy: the Aalst technique

ABSTRACT Introduction: Bladder neck dissection is one of the most delicate surgical steps of robotic-assisted radical prostatectomy (RARP) [1, 2], and it may affect surgical margins rate and functional outcomes [3, 4]. Given the relationship between outcomes and surgical experience [5–7], it is crucial to implement a step-by-step approach for each surgical step of the procedure, especially in the most challenging part of the intervention. In this video compilation, we described the techniques for bladder neck dissection utilized at OLV Hospital (Aalst, Belgium). Surgical Technique: We illustrated five different techniques for bladder neck dissection during RARP. The anterior technique tackles the bladder neck from above until the urethral catheter is visualized, and then the dissection is completed posteriorly. The lateral and postero-lateral approaches involve the identification of a weakness point at the prostate-vesical junction and aim to develop the posterior plane – virtually until the seminal vesicles – prior to the opening of the urethra anteriorly. Finally, we described our techniques for bladder neck dissection in more challenging cases such as in patients with bulky middle lobes and prior surgery for benign prostatic hyperplasia. All approaches follow anatomic landmarks to minimize positive surgical margins and aim to preserve the bladder neck in order to promote optimal functional recovery. All procedures were performed with DaVinci robotic platforms using a 3-instruments configuration (scissors, fenestrated bipolar, and needle driver). As standard protocol at our Institution, urinary catheter was removed on postoperative day two [8]. Conclusions: Five different approaches for bladder neck dissection during RARP were described in this video compilation. We believe that the technical details provided here might be of help for clinicians who are starting their practice with this surgical intervention

Urinary tract infections in patients with spinal cord injuries

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Perioperative radiotherapy is an independent risk factor for major LARS: a cross-sectional observational study

PURPOSE: Sphincter-preserving surgery for rectal cancer is often associated with low anterior resection syndrome (LARS). The aim of our study was to determine the prevalence of LARS in our institution and identify possible risk factors for LARS. Furthermore, we evaluated which of the LARS symptoms was considered most disabling by patients and whether or not there is an adaptation of the LARS score over time. METHODS: This study includes a prospective database of 100 patients who underwent total or partial mesorectal excision between January 2009 and September 2014. Patients were contacted after a median postoperative time of 38 (5-45) months to determine the LARS score and to identify LARS symptoms that were considered most disabling. Uni- and multivariate regression analysis was performed to identify risk factors for LARS and major LARS. Finally, the LARS score was evaluated over time after restoration of bowel continuity. RESULTS: Out of the 100 patients, 16 had minor LARS (score 21-29) and 51 patients had major LARS (score 30-42). Radiotherapy was an independent risk factor for major LARS (p = 0.04). For the majority of patients with major LARS (22%), fragmentation was considered the most disabling complaint. There was no correlation between interval after restoration of bowel continuity and the severity of the LARS score. CONCLUSIONS: Perioperative radiotherapy is an independent risk factor for major LARS. Fragmentation is considered the most disabling complaint in the majority of patients with major LARS. There is no significant adaptation of the LARS score over time.status: publishe

Totally extraperitoneal laparoscopic inguinal hernia repair using a self-expanding nitinol framed hernia repair device: A prospective case series

The use of a self-expanding nitinol framed prosthesis (ReboundHRD(®)) for totally extraperitoneal laparoscopic inguinal hernia repair (TEP-IHR) could solve issues of mesh shrinkage and associated pain. We prospectively evaluated the use of the ReboundHRD(®) mesh for TEP-IHR.publisher: Elsevier articletitle: Totally extraperitoneal laparoscopic inguinal hernia repair using a self-expanding nitinol framed hernia repair device: A prospective case series journaltitle: International Journal of Surgery articlelink: http://dx.doi.org/10.1016/j.ijsu.2017.02.091 content_type: article copyright: © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.status: publishe

Transanal Endoscopic Operation for Benign Rectal Lesions and T1 Carcinoma

Transanal endoscopic operation (TEO) is a minimally invasive technique used for local excision of benign and selected malignant rectal lesions. The purpose of this study was to investigate the feasibility, safety, and oncological outcomes of the procedure and to report the experience in 3 centers.status: publishe