Complex renal masses: Partial or no partial nephrectomy?

Management of high complexity renal masses is always challenging for urologists. Beksac and co-workers made a great effort in collecting data from 144 patients with complex renal masses defined as a RENAL score higher than 10 undergoing robotic partial nephrectomy (RPN). Trifecta was achieved in 62% of the patients. The multi-center design of the study is an important feature considering that 6 surgeons were involved. The study is retrospective and follow up is short therefore data should be managed with caution. Their study confirms the available evidence on the subject, confirming that in expert hands RPN should be performed whenever deemed feasible

Laparoscopic simple prostatectomy vs bipolar plasma enucleation of the prostate in large benign prostatic hyperplasia. a two-center 3-year comparison

Purpose: To compare surgery outcomes and safety of button bipolar enucleation of the prostate vs laparoscopic simple prostatectomy in patients with large prostates (> 80 g) in a two-center cohort study. Methods: All patients with lower urinary tract symptoms due to benign prostatic enlargement (Prostate volume > 80 cc) undergoing button bipolar enucleation of the prostate (BTUEP) or laparoscopic simple prostatectomy (LSP) in two centers were enrolled. Data on clinical history, physical examination, urinary symptoms, uroflowmetry and prostate volume were collected at 0, 1, 3 6, 12, 24 and 36 months. Early and long-term complications were recorded. Results: Overall, 296 patients were enrolled. Out of them, 167/296 (56%) performed a LSP and 129/296 (44%) performed a BTUEP. In terms of efficacy both procedures showed durable results at three years with a reintervention rate of 8% in the LSP group and of 5% in the BTUEP group. In terms of safety, BTUEP and LSP presented similar safety profiles with a 9% of transfusion rate and no major complications. Conclusion: LSP and BTUEP are safe and effective in treating large-volume adenomas with durable results at three years when performed in experienced centers

Laparoscopic simple prostatectomy. a large single center prospective cohort study

Backround: Aim of our study was to analyse outcomes and safety of laparoscopic simple prostatectomy (LSP) in a high volume center. Methods: A consecutive series of men with lower urinary tract symptoms and large prostates (>80cc) prospectively enrolled between November 2015 and December 2017 in one center. All patients underwent laparoscopic simple prostatectomy. Outcomes were evaluated considering the trifecta favourable outcome which was defined as a combination of the following items: (1) no perioperative complications, (2) postoperative IPSS <8, and (3) postoperative Qmax >15 ml/s. Complications were evaluated according to the modified Clavien classification system. Univariate and multivariate binary logistic regression was performed to identify predictors of a positive trifecta outcome. Results: Overall 272 patients were enrolled. At three months after surgery median IPSS total score was 4 (IQR:3/7), median IPSS Qol was 1 (IQR:1/2), median PSA was 0.53 (IQR:0.33/1.00) ng/ml and median Qmax was 23 (17/30) ml/s. All these parameters improved statistically when compared to baseline (p<0.001). The overall complication rate was 21 % however most of the complications were low grade complications according to modified Clavien Dindo classification (Grade ≤2). Overall, 68% of the patients presented a positive trifecta outcome. On multivariate analysis only preoperative Haemoglobin and hospital stay were confirmed predictors of positive trifecta outcome. Conclusions: LSP represents a safe and effective procedure in the treatment of large adenomas. Although RCTs are needed before reaching definitive conclusions, LSP is a promising technique for patients with LUTS and large prostates

How many procedures are needed to achieve learning curve of Millin simple laparoscopic prostatectomy

BACKGROUND: Aim of our study was to evaluate learning curve of the Millin simple prostatectomy analysing three expert laparoscopic surgeons.METHODS: Learning curve of 3 expert laparoscopic surgeons with excellent radical prostatectomy training was evaluated. Surgeon 1 had more than 20 years of experience, while other surgeons had 10 years of experience. The first 45 procedures of the surgeons were considered for analysis. The cumulative sum (CUSUM) technique, one of the methods developed to monitor the performance and quality of the industrial sector, was adopted to analyse learning curves. The variables included to evaluate learning curve of the surgeons were: operative time (OT), hospitalisation (HO) and complication rate.RESULTS: Overall 135 patients were included in the analysis. Median age was 68 (64/74), median prostate volume was 83 (75/97), median Qmax 9 ml/s (6/11) and median IPSS 20 (18/22). Complications included: 9/135 (7%) transfusion, 4/135 (3%) Urinary retention, 3/135 (2%) fever, 1/35 (<1%) reintervention and 1/135 (<1%) conversion. Surgeon 1 presented a lower median operative time when compared to surgeon 2 and 3. No significant differences were recorded in terms of hospitalisation, blood loss and transfusion rate as well as postoperative outcomes. According to the CUSUM analysis the number of procedures needed to achieve a plateau in surgical time is 10/15 procedures (fig 1).CONCLUSIONS: In conclusion, according to our results 15 procedures are needed to reach a plateau in surgical time for trained laparoscopic surgeons