Extended pelvic lymph node dissection at the time of robot-assisted radical prostatectomy: Impact of surgical volume on efficacy and complications in a single-surgeon series

INTRODUCTION: We assessed the impact of surgical volume on perioperative outcomes and complications of robotic extended pelvic lymph node dissection (ePLND). METHODS: From November 2008 to October 2012, a total of 233 consecutive patients with intermediate- or high-risk clinically localized prostate cancer underwent robot-assisted radical prostatectomy (RARP) and ePLND by a single, experienced open and laparoscopic surgeon. Data were prospectively collected. Complications were classified according to the Modified Clavien System. Complications potentially related to ePLND were documented. The minimum follow-up was 3 months. To evaluate the impact of surgical volume on the results, 4 patient subgroups (subgroup 1: cases 1-59; 2: 60-117; 3: 118-175; 4: 176-233) were compared using the Chi-squared and Kruskal-Wallis tests. RESULTS: The mean (range) operative time for ePLND was 79 minutes (range: 48-144), with a steady performance over time (p = 0.784). The count of resected lymph nodes plateaued after 60 procedures (mean [range]: 13 [range: 6-32], 15 [range: 7-34], 17 [range: 8-41], 16 [range: 8-42] in Groups 1 to 4, respectively, p = 0.001). Tumour lymph node involvement was 12% in Groups 1 and 2, 7% in Group 3 and 9% in Group 4 (p = 0.075). Overall, 115 complications were reported in 98/233 patients (42%), with a significant decrease after 175 cases (p = 0.028). In Group 4, 3 patients reported an ePLND-related bleeding requiring open revision. Lymphoceles were detected in 10/233 patients (4.2%) and 1 patient (1.7%) in each of the Groups 2 to 4 required a percutaneous drainage. CONCLUSIONS: A surgeon with extensive experience is expected to achieve a safe learning curve for ePLND during RARP. A learning curve of 60 cases is suggested for optimal lymph node yield

Assessment of prostate cancer with integrated CT-perfusion using a sector-wise approach

OBJECTIVE: The role of computed tomography perfusion (CTP) in characterizing primary prostate cancer (PCa) is not definitely known. The aim of the present study was to investigate the relationship between CTP parameters and histopathological features of PCa tissue, using a sector-wise approach. MATERIAL AND METHODS: Fifty-one patients with biopsy-proven PCa underwent prospectively a CTP scan prior to radical prostatectomy. Blood flow (BF), mean blood volume (BV) and mean transit time (MTT) were calculated, with the prostate being divided into eight sectors. Corresponding sector-wise histopathological analysis of whole-mount prostatectomy specimens was performed to determine tumoral area (mm(2)), mean microvessel density (MVD), Gleason patterns (primary, secondary) and total Gleason score. Spearman's rank correlation coefficient was used to analyze the association between CTP and histopathological parameters. RESULTS: BF correlated weakly with tumoral area [ρs coefficient (p-value): 0.25 (0.00)] and MVD [ρs coefficient (p-value): 0.23 (0.00)]. No valuable correlation was found between CTP parameters and primary and secondary Gleason patterns, whereas total Gleason score was weakly correlated with BV [ρs coefficient (p-value): 0.22 (0.00)] and MTT [ρs coefficient (p-value): 0.25 (0.00)]. CONCLUSION: BF correlates weakly with size and vascularity of PCa. There is a need for further studies to elucidate the association between CTP parameters and other histopathological parameters

Extracorporeal shock wave lithotripsy for distal ureteral calculi: what a powerful machine can achieve

PURPOSE: We assessed the efficacy of extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) for distal ureteral calculi with the HM3 (Dornier Medical Systems, Inc.) lithotriptor. MATERIALS AND METHODS: A total of 585 consecutive patients with distal ureteral calculi were treated with ESWL using an unmodified HM3 lithotriptor. Of these patients 67 referred for treatment only for whom no followup was available were excluded from further analysis. The remaining 518 cases were followed until they were radiologically documented to be stone-free or considered treatment failures. Before ESWL additional procedures were performed in 144 patients, including stone push back, ureteral catheter or Double-J (Medical Engineering Corp., New York, New York) stent placement, percutaneous nephrostomy, ureteral endoscopic maneuvers or stone basket manipulation. A total of 374 patients needed no preliminary treatment before ESWL. RESULTS: Of the 518 patients 469 (91%) were successfully treated with 1 ESWL session, while 49 (9%) needed 2 or 3. Manipulation after ESWL was performed in 22 cases, including stent placement, percutaneous nephrostomy, ureteral endoscopic stone removal and a stone basket procedure. On day 1 after ESWL 327 patients (63%) were stone-free, 158 (30%) had less than 5 mm. fragments and 33 (7%) had more than 5 mm. fragments. At 3 months the stone-free rate increased to 97%. CONCLUSIONS: These data show that ESWL for distal ureteral calculi with the powerful unmodified HM3 lithotriptor has a high success rate with a low rate of minimally traumatic manipulations before and after intervention. Results in terms of the re-treatment and stone-free rates are superior to those of any other second or third generation lithotriptor and comparable to the results of the best ureteroscopic series

Safety and efficacy of robot-assisted radical prostatectomy in a low-volume center: a 6-year single-surgeon experience

AIM:To analyze safety and efficacy of robot-assisted radical prostatectomy (RARP) in a low-volume centre. PATIENTS AND METHODS:From 2008 to 2015, 400 consecutive patients undergoing RARP were prospectively enrolled. Complications were classified according to the Modified Clavien System. Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen (PSA) values ≥0.2 ng/ml. Functional outcomess were assessed using validated, self-administered questionnaires. RESULTS:Median patient age was 64.5 years. Mean standard deviation (SD) preoperative PSA level was 11.3 (11.7) ng/ml. Median interquartile range (IQR) follow-up was 36 (12-48) months. Overall complication rate was 27.7% (minor complications rate 16.2%). Overall 1-, 3- and 6-year BCR-free survival rates were 85.7%, 77.5% and 53.9%, respectively; these rates were 94.1%, 86.2% and 70.1% in pT2 diseases. At follow-up, 98.4% of patients were fully continent (median (IQR) time to continence was 2 (1-3) months) and 68.2% were potent (median (IQR) time to potency of 3 (3-4) months). CONCLUSION:RARP appears to be a valuable option for treating clinically localised prostate cancer also in a low-volume institution

Robot-assisted radical prostatectomy in the setting of previous abdominal surgery: perioperative results, oncological and functional outcomes, and complications in a single surgeon's series

BACKGROUND: Data on safety and efficacy of robot-assisted radical prostatectomy (RARP) after previous abdominal surgery are scarce. Hence, we assessed perioperative, oncological and functional outcomes, and complications of RARP in patients with previous abdominal surgery after 1-year minimum follow-up. MATERIALS AND METHODS: Prospectively collected data from 339 consecutive patients undergoing transperitoneal RARP by a single surgeon (AM) between November 2008 and May 2014 were analysed. Complications were classified according to Modified Clavien System. Biochemical recurrence (BCR) was defined as two consecutive PSA values ≥ 0.2 ng/ml. Functional outcomes were assessed using validated, self-administered questionnaires. In particular, only patients undergoing nerve-sparing RARP with no erectile dysfunction (baseline IIEF-5 score >21) and no use of phosphodiesterase-5 inhibitors preoperatively who were interested in erections and required no adjuvant therapy (radiation, orchiectomy and androgen-deprivation therapy) were evaluated concerning potency recovery. Patients without and with previous abdominal surgery were compared using Mann-Whitney and chi-square tests (or Fisher exact test). RESULTS: On 339 patients, 247 (71.6%) had not undergone previous abdominal surgery (Group 1) and 92 (28.4%) were pre-operated (Group 2). There were no statistically significant differences between Groups 1 and 2 regarding mean operative time (260 vs. 257 min; p = 0.597), median number of resected nodes (16 vs. 17; p = 0.484), mean length of stay (7.2 vs. 7.1 d; p = 0.151), positive surgical margin (12.5% vs. 16.3%; p = 0.233) and complication rates (26.7% vs. 31.5%; p = 0.187). Median (IQR) follow-up was 36 (12-48) months. For Groups 1 and 2, BCR-free survival rates were 78.5% and 79.8% (p = 0.467); continence rates were 97.9% and 100% (p = 0.329), whereas a potency recovery was achieved in 69.5% and 62.2% of patients (p = 0.460), respectively. CONCLUSIONS: Transperitoneal RARP is a safe and efficient treatment for clinically localised prostate cancer even in patients with previous abdominal surgery. However, further studies with higher number of patients are warranted

Ultrasound assessment of detrusor thickness in men-can it predict bladder outlet obstruction and replace pressure flow study?

PURPOSE: We estimated the diagnostic accuracy of ultrasound detrusor thickness measurement for BOO and investigated whether this method can replace PFS for the diagnosis of BOO in some patients with lower urinary tract symptoms. MATERIALS AND METHODS: Detrusor thickness was measured by linear ultrasound (7.5 MHz) at a filling volume of greater than 50% of cystometric capacity in 102 men undergoing PFS for LUTS. All patients with prior treatment for bladder outlet obstruction and those with underlying neurological disorders were excluded from analysis. Detrusor thickness was correlated with PFS data. Obstruction was defined according to the Abrams-Griffiths nomogram. RESULTS: Detrusor thickness was significantly higher (p <0.0001) in obstructed (61 cases, median detrusor thickness 2.7 mm, IQR 2.4 to 3.3) compared to unobstructed (18 cases, median detrusor thickness 1.7 mm, IQR 1.5 to 2) as well as equivocal (23 cases, median detrusor thickness 1.8 mm, IQR 1.5 to 2.2) cases. A weak to medium Spearman correlation was found between detrusor thickness and PFS parameters. For a diagnosis of BOO, detrusor thickness of 2.9 mm or greater had a positive predictive value of 100%, a negative predictive value of 54%, specificity of 100% and sensitivity of 43%. ROC analysis revealed that detrusor thickness had a high predictive value for BOO with an AUC of 0.88 (95% CI 0.81-0.94). CONCLUSIONS: In men with LUTS without prior treatment and/or neurological disorders, ultrasonographically assessed detrusor thickness 2.9 mm or greater has a high predictive value for BOO and can replace PFS for the diagnosis of BOO. However, this cutoff value needs to be validated in a larger study population

Prospective randomized trial comparing titanium clips to bipolar coagulation in sealing lymphatic vessels during pelvic lymph node dissection at the time of robot-assisted radical prostatectomy

Lymphocele is the most common complication after pelvic lymph node dissection (PLND). Over the years, various techniques have been introduced to prevent lymphocele, but no final conclusion can be drawn regarding the superiority of one technique over another. In this prospective study, 220 patients undergoing robot-assisted radical prostatectomy between 2012 and 2015 were randomized to receive titanium clips (group A, n=110) or bipolar coagulation (group B, n=110) to seal lymphatic vessels at the level of the femoral canal during extended PLND (ePLND). Ultrasound examination was used to detect lymphoceles at 10 and 90 d after surgery. Lymphocele was defined as any clearly definable fluid collection and was considered clinically significant when requiring treatment. There were no statistically significant differences between groups A and B regarding overall lymphocele incidence (47% vs 48%; difference -0.91%, 95% confidence interval [CI] -2.6 to 0.7; p=0.9) and the rate of clinically significant lymphocele [5% vs 4%; difference 0.75%, 95% CI, 0.1-3.2; p=0.7]. The two groups were comparable regarding mean (±SD) lymphocele volume (30±32 vs 35±39ml; p=0.6), lymphocele location (unilateral, 37% vs 35%, p=0.7; bilateral, 13% vs 14%, p=0.9), and time to lymphocele diagnosis (95% vs 98% on postoperative day 10; p=0.5). In conclusion, this trial failed to identify a difference in lymphocele occurrence between clipping and coagulation of the lymphatic vessels at the level of the femoral canal during robot-assisted ePLND for prostate cancer. PATIENT SUMMARY: In this study we compared the frequency of postoperative complications after sealing lymphatic vessels from the leg to the abdomen using metallic clips or electrical coagulation during robot-assisted surgery for prostate cancer. We found no difference in postoperative complications between the two methods

Diagnostic value of Xpert® BC Detection, Bladder Epicheck®, Urovysion® FISH and cytology in the detection of upper urinary tract urothelial carcinoma.

PURPOSE Following the current guidelines, diagnosis and staging for upper urinary tract tumours (UTUC) can be performed with Computed Tomography, urography, ureterorenoscopy (URS) and selective cytology. The aim of the study was to evaluate the performance of the Xpert®-BC-Detection and the Bladder-Epicheck®-test in the detection of UTUC and compare it with cytology and the Urovysion®-FISH test using histology and URS as gold standard. METHODS A total of 97 analyses were collected through selective catheterization of the ureter before URS to test for cytology, Xpert®-BC-Detection, Bladder-Epicheck® and Urovysion®-FISH. Sensitivity, specificity, and predictive values were calculated using histology results/URS as reference. RESULTS Overall sensitivity was 100% for Xpert®-BC-Detection, 41.9% for cytology, 64.5% for Bladder-Epicheck® and 87.1% for Urovysion®-FISH. The sensitivity of Xpert®-BC-Detection was 100% in both, LG and HG tumours, sensitivity of cytology increased from 30.8% in LG to 100% in HG, for Bladder-Epicheck® from 57.7% in LG to 100% in HG and of Urovysion®-FISH from 84.6% in LG to 100% in HG tumours. Specificity was 4.5% for Xpert®-BC-Detection, 93.9% for cytology, 78.8% for Bladder-Epicheck® and 81.8% for Urovysion®-FISH. PPV was 33% for Xpert®-BC-Detection, 76.5% for cytology, 58.8% for Bladder-Epicheck® and 69.2% for Urovysion®FISH. NPV was 100% for Xpert®-BC-Detection, 77.5% for cytology, 82.5% for Bladder-Epicheck® and 93.1% for Urovysion®FISH. CONCLUSION Bladder-Epicheck® and Urovysion®FISH along with cytology could be a helpful ancillary method in the diagnosis and follow-up of UTUC while due to its low specificity Xpert®-BC Detection seems to be of limited usefulness