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

Niraparib in patients with metastatic castration-resistant prostate cancer and DNA repair gene defects (GALAHAD): a multicentre, open-label, phase 2 trial

Background Metastatic castration-resistant prostate cancers are enriched for DNA repair gene defects (DRDs) that can be susceptible to synthetic lethality through inhibition of PARP proteins. We evaluated the anti-tumour activity and safety of the PARP inhibitor niraparib in patients with metastatic castration-resistant prostate cancers and DRDs who progressed on previous treatment with an androgen signalling inhibitor and a taxane. Methods In this multicentre, open-label, single-arm, phase 2 study, patients aged at least 18 years with histologically confirmed metastatic castration-resistant prostate cancer (mixed histology accepted, with the exception of the small cell pure phenotype) and DRDs (assessed in blood, tumour tissue, or saliva), with progression on a previous next-generation androgen signalling inhibitor and a taxane per Response Evaluation Criteria in Solid Tumors 1.1 or Prostate Cancer Working Group 3 criteria and an Eastern Cooperative Oncology Group performance status of 0–2, were eligible. Enrolled patients received niraparib 300 mg orally once daily until treatment discontinuation, death, or study termination. For the final study analysis, all patients who received at least one dose of study drug were included in the safety analysis population; patients with germline pathogenic or somatic biallelic pathogenic alterations in BRCA1 or BRCA2 (BRCA cohort) or biallelic alterations in other prespecified DRDs (non-BRCA cohort) were included in the efficacy analysis population. The primary endpoint was objective response rate in patients with BRCA alterations and measurable disease (measurable BRCA cohort). This study is registered with ClinicalTrials.gov, NCT02854436. Findings Between Sept 28, 2016, and June 26, 2020, 289 patients were enrolled, of whom 182 (63%) had received three or more systemic therapies for prostate cancer. 223 (77%) of 289 patients were included in the overall efficacy analysis population, which included BRCA (n=142) and non-BRCA (n=81) cohorts. At final analysis, with a median follow-up of 10·0 months (IQR 6·6–13·3), the objective response rate in the measurable BRCA cohort (n=76) was 34·2% (95% CI 23·7–46·0). In the safety analysis population, the most common treatment-emergent adverse events of any grade were nausea (169 [58%] of 289), anaemia (156 [54%]), and vomiting (111 [38%]); the most common grade 3 or worse events were haematological (anaemia in 95 [33%] of 289; thrombocytopenia in 47 [16%]; and neutropenia in 28 [10%]). Of 134 (46%) of 289 patients with at least one serious treatment-emergent adverse event, the most common were also haematological (thrombocytopenia in 17 [6%] and anaemia in 13 [4%]). Two adverse events with fatal outcome (one patient with urosepsis in the BRCA cohort and one patient with sepsis in the non-BRCA cohort) were deemed possibly related to niraparib treatment. Interpretation Niraparib is tolerable and shows anti-tumour activity in heavily pretreated patients with metastatic castration-resistant prostate cancer and DRDs, particularly in those with BRCA alterations

Early Catheter Removal after Robot-assisted Radical Prostatectomy: Surgical Technique and Outcomes for the Aalst Technique (ECaRemA Study)

Background Robot-assisted radical prostatectomy (RARP) is a widespread option for the treatment of patients with clinically localised prostate cancer. Modifications in the surgical technique may help to further improve functional outcomes. Objective To assess the outcome of early catheter removal 48 h after surgery, as opposed to standard catheter removal 6 d after surgery following RARP, using a newly developed surgical technique for posterior reconstruction and anastomosis (Aalst technique). Design, setting, and participants Patients scheduled for RARP were prospectively scheduled for early catheter removal at postoperative d 2 (group A, n = 37) and standard catheter removal at postoperative d 6 (group B, n = 37). Surgical procedure RARP was performed using the Da Vinci Si system. The Aalst technique for the urethro-vesical anastomosis including posterior reconstruction was used as previously described. Outcome measurements and statistical analysis The primary endpoint was spontaneous voiding after catheter removal. Secondary endpoints were rate of anastomotic urinary leakage after catheter removal, presence and severity of urethral, perineal, and abdominal pain, as well as patient's bother after catheter removal using visual analogue scale (VAS) scores. Rate and severity of urinary incontinence after catheter removal were assessed using the International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms Module (ICIQ-MLUTS) questionnaire. Results and limitations There was no significant difference between the groups with regard to baseline and perioperative parameters, as well as pathological features; however, significantly more patients underwent bilateral nerve-sparing procedures in group A (34 vs 23, p = 0.008). After catheter removal, patients in both groups showed spontaneous voiding, whereas only 11% and 8% of the patients in group A and group B experienced urinary retention after catheter removal (p = 0.7). Patients in group B had significantly higher maximum flow rates, but lower voided volumes after catheter removal in comparison with patients in group A (21 ml/s vs 10 ml/s, p 64 0.001 and 170 ml vs 200 ml, p 64 0.001, respectively). ICIQ-MLUTS questionnaire and VAS scores showed no significant differences between the groups at any time point. Conclusions The Aalst technique allows the removal of catheters 2 d after RARP and results in spontaneous voiding. Early removal showed no increased rate of urinary leakage, no negative impact on short-term continence and on perineal, urethral or penile pain, and no increase in urinary retention rates. Future studies have to confirm these results with longer follow-up including detailed parameters on return to daily activity. Patient summary We provide evidence that it is possible to remove the bladder catheter as early as 2 d after robot-assisted radical prostatectomy without any negative effects on voiding and pain parameters. Thus, leaving the hospital early without a catheter in place could represent a significant and relevant benefit for the patient. \ua9 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved

Robot-assisted Simple Prostatectomy for Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Enlargement: Surgical Technique and Outcomes in a High-volume Robotic Centre

Background Robot-assisted simple prostatectomy (RASP) is a minimally invasive procedure for treatment of patients with lower urinary tract symptoms (LUTS) due to large benign prostatic enlargement (BPE). Objective To present the perioperative and short-term functional outcomes of RASP in a large series of patients with LUTS due to BPE treated in a high-volume referral center. Design, setting, and participants We retrospectively collected data for 67 consecutive patients who underwent RASP from October 2008 to August 2014. Surgical procedure RASP was performed using a Da Vinci S or Si system with a transvesical approach. Measurements Complications were graded according to the Clavien-Dindo system. Continuous variables are reported as median and interquartile range (IQR). Comparison of preoperative and postoperative outcomes was assessed by Wilcoxon test. A two-sided value of p < 0.05 was considered statistically significant. Results and limitations The median preoperative prostate volume was 129 ml (IQR 104-180). For the 45 patients who did not have an indwelling catheter, the median preoperative International Prostate Symptom Score (IPSS) was 25 (20.5-28), the median maximum flow rate (Qmax) was 7 ml/s (IQR 5-11), and the median post-void residual volume (PVRV) was 73 ml (IQR 40-116). The median operative time was 97 min (IQR 80-127) and the median estimated blood loss was 200 ml (IQR 115-360). The postoperative complication rate was 30%, including three cases (4.5%) with grade 3b complications (major bleeding requiring cystoscopy and coagulation). The median catheterization time was 3 d (IQR 2-4) and the median length of stay was 4 d (IQR 3-5). The median follow-up was 6 mo (IQR 2-12). At follow-up, the median IPSS was 3 (IQR 0-8), the median Qmax was 23 ml/s (IQR 16-35), and the median PVRV was 0 ml (IQR 0-36) (all p < 0.001 vs baseline values). The retrospective design is the major study limitation. Conclusions Our data indicate good perioperative outcomes, an acceptable risk profile, and excellent improvements in patient symptoms and flow scores at short-term follow-up following RASP. Patient summary We analyzed the perioperative and functional outcomes of robot-assisted simple prostatectomy in the treatment of male patients with lower urinary tract symptoms due to large prostatic adenoma. The procedure was associated with a relatively low risk of complications and excellent functional outcomes, including considerable improvements in symptoms and flow performance. We can conclude that the procedure is a valuable option in the treatment of such patients. However, comparative studies evaluating the efficacy of the procedure in comparison with endoscopic treatment of large prostatic adenomas are neede

Robot-assisted nephroureterectomy for upper tract urothelial carcinoma : results from three high-volume robotic surgery institutions

Robot-Assisted NephroUreterectomy (RANU) represents a minimally invasive alternative to open NephroUreterectomy (NU) for management of Upper Tract Urothelial Carcinoma (UTUC) but its oncologic safety is still controversial. The objective of this study was to investigate the peri-operative, pathologic and oncologic outcomes of RANU for UTUC. From 2008 to 2017, 78 patients diagnosed with UTUC and elected for RANU at 3 high-volume robotic surgery centres were retrospectively assessed. Surgery was performed using da Vinci Si(R) and Xi(R) systems. RANU was done adhering to oncological principles as in open surgery. The outcomes of the study were: (1) peri-operative morbidity, namely intra- and post-operative complications, blood loss, length of hospital stay and operative time; (2) oncologic outcomes, namely overall survival (OS) and recurrence-free survival (RFS). Peri-operative overall complication rate was 24.4% and high-grade complication rate was 2.6%. Median blood loss, length of hospital stay and operative time were 124 ml, 4 days and 167 min. Lymphadenectomy was performed in 31 (41%) patients. Lymph-node involvement was present in 9 (29%) patients. At median follow-up of 15 months, 2- and 4-year OS were 79% and 66%, respectively, and RFS was 63% and 53%. Peritoneal dissemination was recorded in 1 (1.3%) patient with pT4N2R1 UTUC. Our study is limited by the relatively small cohort of patients and its retrospective character. RANU as minimally invasive treatment for patients with UTUC is safe and feasible. Post-operative morbidity is low and major complications are rare. Oncologic outcomes are acceptable and no evidence of increased risk of peritoneal dissemination is recorded. Long-term data are needed. RANU should be regarded as an alternative to open surgery for UTUC that can offer good peri-operative and oncologic results

Metachronous metastasis of renal cell carcinoma to the urinary bladder: a case report

We report a case of intravesical metastasis of a clear cell renal cell carcinoma. In renal cell carcinoma 16% of patients present with metastatic disease. Renal cell carcinoma can metastasize to nearly every organ, although metastatic spread to the urinary bladder is rare, with fewer than 70 described cases. The route and pattern of metastatic spread is not yet fully understood and different pathways are suggested. Gross haematuria is the presenting symptom in the majority of cases. These intravesical metastases may be synchronous or metachronous and can be solitary or part of polymetastatic disease. No standard treatment can be suggested due to the rare nature of this phenomenon, and treatment varies from transurethral resection, partial or complete cystectomy to systemic therapy. Prognosis in patients with a solitary bladder lesion that developed metachronously is rather good, whereas poor prognosis can be expected in patients with synchronous and multiple metastases

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: Results of a Belgian retrospective multicentre survey

Objectives: To evaluate the technical and oncologic feasibility of laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma. Methods: A retrospective survey of 100 patients, treated with laparoscopic nephroureterectomy in 10 Belgian centres, was performed. Most procedures were performed transperitoneally. The distal ureter was managed by open surgery in 55 patients and laparoscopically in 45 patients. The mean follow-up was 20 mo. Results: Mean operation time was 192 min and mean blood loss 234 ml. The conversion rate was 7%. Important postoperative complications were seen in 9%. Pathologic staging was pTa in 31 patients, pT1 in 23, pT2 in 12, pT3 in 33, and pT4 in 1, concomittant pTis in 3. Pathologic grade was G1 in 24 patients, G2 in 28, and G3 in 48. Negative surgical margins were obtained in all but one patient. Twenty-five patients developed progressive disease (24%) at a mean postoperative time of 9 mo (local recurrence in 8%, metastases in 11%, both in 5%). Progression was 0% for pTa, 17% for pT1, 17% for pT2, 51% for pT3, and 100% for pT4. Cancer-specific survival was 100% for pTa, 86% for pT1, 100% for pT2, 77% for pT3, and 0% for pT4. Conclusion: Laparoscopic nephroureterectomy appears to be a technically and oncologically feasible operation. To prevent tumour seeding, one should avoid opening the urinary tract and should extract the specimen with an intact organ bag. The high local recurrence rate in this study probably reflects the high percentage of high-grade and high-stage tumours in this study. (C) 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved