30 research outputs found
Response to Re: External beam radiotherapy and radical prostatectomy are associated with better survival in Asian prostate cancer patients
No full textOn-clamp versus purely off-clamp robot-assisted partial nephrectomy in solitary kidneys: comparison of perioperative outcomes and chronic kidney disease progression at two high-volume centers
No full textBACKGROUND: Minimal literature describes the impact of hilar control on the progression to chronic kidney disease (pCKD) after robotic partial nephrectomy (RPN) in solitary kidneys (SK). The aim of this study was to compare purely off-clamp (ocRPN) vs. on-clamp robotic partial nephrectomy (onRPN) in SK and to identify predictors of pCKD at two high-volume centers. METHODS: Between December 2013 and October 2019, 54 patients with SK underwent ocRPN and onRPN for renal tumors at two institutions. Baseline and perioperative data were analyzed. Newly onset of CKD stage 3b,4,5 (CKD3b,4,5) was assessed by Kaplan-Meier curves and compared for warm ischemia time (WIT) with the log-rank test. Cox regression analysis was used to identify predictors of pCKD. RESULTS: At a median follow-up of 13 months (IQR 6.3-34), newly onset of CKD3b and CKD 4.5 were observed in 11.1% and 7.4% of patients, respectively. onRPN was associated with a higher risk of progression to CKD 3b,4,5 stages (P=0.034) and higher rate of perioperative complications (P=0.03). On univariable analysis eGFR at discharge (eGFRd), positive surgical margins status (PSM) and WIT were predictors of newly onset of CKD3b,4,5 (each P<0.05). Multivariable analysis identified eGFRd (HR 0.88; CI 95% 0.81-0.96) and WIT (HR 1.09; CI 95% 1.02-1.16) as independent predictors of pCKD (each P<0.01). Main limitations include the retrospective nature of the study, the short-term follow-up and the lack of data adjustment for parenchymal volume loss. CONCLUSIONS: eGFRd and WIT during RPN are independent predictors of pCKD in SK. In this setting a critical reduction of WIT should be achieved according to the oncologic outcome. In patients with SK, WIT represents the only surgical modifiable factor of RPN for avoiding a quicker onset of pCKD
Development of a nomogram to predict achievement of trifecta outcomes in patients receving robot-assisted radical cystectomy with intracorporeal orthotopic neobladder
No full textINTRODUCTION AND OBJECTIVE: Robot-assisted radical cystectomy (RARC) with orthotopic neobladder (ON) is associated with heterogeneous surgical, functional and oncological outcomes. We propose a combination of three standardized and reproducible postoperative criteria (Trifecta) to optimize outcomes reporting after RARC with ON and we developed a nomogram to predict probability of achieving trifecta.
METHODS: We defined the "trifecta" as the combination of daily urinary continence, no reoperations (meaning neither post-operative complications Clavien-Dindo ≥ 3 nor other surgical interventions related to RARC/ON, after discharge) and recurrence-free status, all assessed at one year. A total of 137 consecutive patients who underwent RARC with intracorporeal ON for bladder cancer were used to generate a nomogram predicting probability of achieving trifecta outcomes. The discrimination accuracy was measured by concordance index (CI). Calibration plot was generated with 200 bootstrap resampling. A decision curve analysis was performed to assess the net benefit of the model.
RESULTS: Overall, 137 patients were included in the analysis (Table 1). The trifecta was achieved by 72 (53%) patients. On multivariable logistic regression analysis, age, ASA score, body mass index and neoadjuvant chemotherapy were significant predictors of trifecta achievement. The developed nomogram had a 0.71 CI (Figure 1A) and was well calibrated (Figure 1B); on decision curve analysis, the net benefit of using the model was evident for probabilities ranging between 25% and 70% (Figure 1C). The small sample size and the lack of external validation are the main limitations of this study.
CONCLUSIONS: This newly defined trifecta is the first standardized and reproducible system specifically designed to provide a comprehensive summary of global results after RARC-iN. The developed nomogram is an easy clinical tool to predict probability of trifecta achievement at 12-mo follow-up evaluation
“Single Knot–Single Running Suture” Vesicourethral Anastomosis with Posterior Musculofascial Reconstruction during Robot-Assisted Radical Prostatectomy: A Step-by-Step Guide of Surgical Technique
No full textBackground: Our aim is to describe Gallucci's (VV-G) technique for vesicourethral anastomosis and posterior musculofascial reconstruction (PMFR) during robot-assisted radical prostatectomy (RARP) and to assess early urinary continence recovery and perioperative outcomes. VV-G consists of a "single knot-single running suture" vesicourethral anastomosis with PMFR. Methods: Between September 2019 and October 2021, we prospectively compared VV-G vs. conventional Van Velthoven anastomosis (VV-STD) during RARP. We excluded patients with urinary incontinence, pelvic radiotherapy, and urethral and BPH surgery prior to RARP. Social continence (SC) recovery, perioperative complications, and length of hospital stay (LOS) were compared between VV-G vs. VV-STD. SC was defined as 0-1 pad/die. We applied 1:1 propensity score matching (PSM) adjusting for different covariates (age, Charlson Comorbidity Index, BMI, prostate volume, nerve-sparing and lymph node dissection). Results: From 166 patients, 1:1 PSM resulted in two equally sized groups of 40 patients each with no residual differences (all p ≥ 0.2). VV-G yielded higher 3-month SC rates than VV-STD (97.5 vs. 55.0%, p < 0.001). A tiny difference was still recorded at one-year follow-up (97.5 vs. 80.0%, p = 0.029, HR: 2.90, 95% CI: 1.74-4.85, p < 0.001). Conversely, we observed no differences in any perioperative complications (15.0 vs. 22.5%, OR: 0.61, 95% CI 0.19-1.88, p = 0.4) and LOS (3 vs. 4 days, Δ: -0.69 ± 0.61, p = 0.1). Conclusions: VV-G significantly improved early SC recovery without increasing perioperative morbidity. In our opinion, VV-G represents an easy-to-learn and easy-to-teach technique due to its single-suture, single-knot, and symmetrical design
A novel pathway to detect muscle-invasive bladder cancer based on integrated clinical features and VI-RADS score on MRI: results of a prospective multicenter study
No full textPurpose To determine the clinical, pathological, and radiological features, including the Vesical Imaging-Reporting and Data System (VI-RADS) score, independently correlating with muscle-invasive bladder cancer (BCa), in a multicentric national setting. Method and Materials Patients with BCa suspicion were offered magnetic resonance imaging (MRI) before trans-urethral resection of bladder tumor (TURBT). According to VI-RADS, a cutoff of >= 3 or >= 4 was assumed to define muscle-invasive bladder cancer (MIBC). Trans-urethral resection of the tumor (TURBT) and/or cystectomy reports were compared with preoperative VI-RADS scores to assess accuracy of MRI for discriminating between non-muscle-invasive versus MIBC. Performance was assessed by ROC curve analysis. Two univariable and multivariable logistic regression models were implemented including clinical, pathological, radiological data, and VI-RADS categories to determine the variables with an independent effect on MIBC. Results A final cohort of 139 patients was enrolled (median age 70 [IQR: 64, 76.5]). MRI showed sensitivity, specificity, PPV, NPV, and accuracy for MIBC diagnosis ranging from 83-93%, 80-92%, 67-81%, 93-96%, and 84-89% for the more experienced readers. The area under the curve (AUC) was 0.95 (0.91-0.99). In the multivariable logistic regression model, the VI-RADS score, using both a cutoff of 3 and 4 (P < .0001), hematuria (P = .007), tumor size (P = .013), and concomitant hydronephrosis (P = .027) were the variables correlating with a bladder cancer staged as >= T2. The inter-reader agreement was substantial (k = 0.814). Conclusions VI-RADS assessment scoring proved to be an independent predictor of muscle-invasiveness, which might implicate a shift toward a more aggressive selection approach of patients' at high risk of MIBC, according to a novel proposed predictive pathway
External Validation of a Novel Comprehensive Trifecta System in Predicting Oncologic and Functional Outcomes of Partial Nephrectomy: Results of a Multicentric Series
No full textBackground: To validate a novel trifecta for evaluating outcomes of partial nephrectomy (PN) on a multicentric dataset. Methods: Between 2007 and 2020, three renal cancer databases were queried for patients with solitary renal masses who underwent PN (n = 649). Trifecta was estimated for overall cohort and contributing centers. Overall survival (OS), cancer-specific survival (CSS) and end-stage renal disease (ESRD) probabilities were assessed by Kaplan–Meier. Cox regression was used to identify predictors of OS, CSS, ESRD. For all analyses, a p < 0.05 was considered significant. Results: At a median follow-up of 22.7 months (IQR 12.5–76.5) overall trifecta was 76.7% [Centre A; (n = 230; 68.6%), B (n = 68; 77.3%), C (n = 200; 88.4%); p = 0.001). On Kaplan–Meier, patients achieving trifecta exhibited higher OS (p = 0.024), higher CSS (p = 0.015) and lower ESRD rates (p = 0.024). On multivariable analysis, age (HR 1.04; 95% CI 1.01–1.08) and trifecta (HR 0.34; 95% CI 0.15–0.76) were independent predictors of OS while pT stage (HR 1.95; 95% CI 0.45–8.43) and trifecta (HR 0.33; 95% CI 0.16–0.67) were predictors of CSS (each p < 0.01). Preoperative CKD stage ≥ 3a (HR 13.1; 95% CI 4.07–42.6) and trifecta (HR 0.41; 95% CI 0.19–0.87) were independent predictors of ESRD (each p < 0.05). Conclusions: On external validation, trifecta was an independent predictor of all PN endpoints, regardless of hilar control and ischemia duration
Minimally Invasive Partial vs. Total Adrenalectomy for the Treatment of Unilateral Primary Aldosteronism: A Systematic Review and Meta‐Analysis
No full textBackground: This systematic review and metanalysis was conducted to assess differences between perioperative and functional outcomes in patients undergoing minimally‐invasive partial (mi‐PA) and total adrenalectomy (mi‐TA) for unilateral primary aldosteronism (uPHA). Material and Methods: Multiple scientific databases (PUBMED, Web of Science, and Cochrane Library) were searched up to November 2021 for surgical series comparing mi‐PA vs. mi‐TA for uPHA according to the PRISMA statement. Primary outcomes of interest were perioperative and functional outcomes. Results: Overall, a total of 802 patients from six eligible studies were identified, with mi‐ PA and mi‐TA performed in 40.4% (n = 324) and 59.6% (n = 478) of cases, respectively. No differences were recorded between the two groups according to number of transfusions, EBL and Clavien– Dindo complications ≥2. Similarly, no differences in clinical success, persistence of postoperative hypokalemia and improvement in HTN were reported between mi‐PA and mi‐TA. Conclusions: In a uPHA setting, mi‐PA and mi‐TA provide comparable perioperative and functional outcomes despite the use of mi‐PA remains limited to patients with small adenoma size, or hereditary/bilateral disease. Due to limited use of standardized reporting criteria in most of current series, the quest for a superiority of mi‐PA over mi‐TA in the treatment of uPHA still remains open
Robotic Surgery in Urology: History from PROBOT® to HUGOTM
No full text: The advent of robotic surgical systems had a significant impact on every surgical area, especially urology, gynecology, and general and cardiac surgery. The aim of this article is to delineate robotic surgery, particularly focusing on its historical background, its evolution, its present status, and its future perspectives. A comprehensive literature review was conducted upon PubMed/MEDLINE, using the keywords "robotic surgical system", "robotic surgical device", "robotics AND urology". Additionally, the retrieved articles' reference lists were investigated. Analysis concentrated on urological surgical systems for laparoscopic surgery that have been given regulatory approval for use on humans. From the late 1980s, before daVinci® Era in 2000s, ancestor platform as Probot® and PUMA 560 were described to outline historical perspective. Thus, new robotic competitors of Intuitive Surgical such as Senhance®, Revo-I®, Versius®, Avatera®, Hinotori®, and HugoTM RAS were illustrated. Although daVinci® had high level competitiveness, and for many years represented the most plausible option for robotic procedures, several modern platforms are emerging in the surgical market. Growing competition through unique features of the new robotic technologies might extend applications fields, improve diffusion, and increase cost-effectiveness procedures. More experiences are needed to identify the role of these new advancements in surgical branches and in healthcare systems
Comparison of Perioperative, Functional, and Oncologic Outcomes of Open vs. Robot-Assisted Off-Clamp Partial Nephrectomy: A Propensity Scored Match Analysis
No full textOff-clamp partial nephrectomy represents one of the latest developments in nephron-sparing surgery, with the goal of preserving renal function and reducing ischemia time. The aim of this study was to evaluate and compare the functional, oncologic, and perioperative outcomes between off-clamp robot-assisted partial nephrectomy (off-C RAPN) and off-clamp open partial nephrectomy (off-C OPN) through a propensity score-matched (PSM) analysis. A 1:1 PSM analysis was used to balance variables potentially affecting postoperative outcomes. To report surgical quality, 1 year trifecta was used. Univariable Cox regression analysis was performed to identify predictors of trifecta achievement. The Kaplan-Meier method was used to compare cancer-specific survival (CSS), overall survival (OS), disease-free survival (DFS), and metastasis-free survival (MFS) probabilities between groups. Overall, 542 patients were included. After PSM analysis, two homogeneous cohorts of 147 patients were obtained. The off-C RAPN cohort experienced shorter length of stay (LoS) (3.4 days vs. 5.4 days; p < 0.001), increased likelihoods of achieving 1 year trifecta (89.8% vs. 80.3%; p = 0.03), lower postoperative Clavien-Dindo ≤ 2 complications (1.3% vs. 18.3%, p < 0.001), and lower postoperative transfusion rates (3.4% vs. 12.2%, p = 0.008). At univariable analysis, the surgical approach (off-C RAPN vs. off-C OPN, OR 2.22, 95% CI 1.09-4.46, p = 0.02) was the only predictor of 1 year trifecta achievement. At Kaplan-Meier analysis, no differences were observed between the two groups in terms of OS (log-rank p = 0.451), CSS (log-rank p = 0.476), DFS (log-rank p = 0.678), and MFS (log-rank p = 0.226). Comparing RAPN and OPN in a purely off-clamp scenario, the minimally invasive approach proved to be a feasible and safe surgical approach, with a significantly lower LoS and minor rate of postoperative complications and transfusions as a result of improved surgical quality expressed by higher 1 year trifecta achievement
Long-term oncologic and functional outcomes following robot-assisted radical cystectomy and intracorporeal Padua ileal bladder. Results from a single high-volume center
No full textPurpose: To report long-term oncologic and functional outcomes of a large consecutive single center series of Robot-assisted radical cystectomy (RARC)- intracorporeal (IC) Urinary Diversion (UD), identifying their predicting factors. Methods: A single center Bladder cancer (BC) database was queried for "RARC" and "ICUD", including patients treated between January 2012 and September 2020. Kaplan-Meier curves were assessed disease-free (DFS), cancer-specific (CSS) and overall survival (OS) probability. Univariable (UV) and multivariable (MV) analysis were adopted to identify predictors of DFS, CSS and OS. Kaplan-Meier method evaluated day- and night-time continence recovery probabilities; UV and MV analysis were adopted to identify predictors of Day-time continence. Results: Overall, 251 patients were included. Among them, 192 patients underwent intracorporeal ileal orthotopic neobladder (ION) (76.5%). Five-year DFS, CSS and OS rates were 66.5%, 65.4% and 61.5%; pT stage ≥ 3 and pathologic nodal involvement were identified as negative independent predictors of DFS (HR 2.39, p = 0.001, HR 4.64, p ≤ 0.001), CSS (HR 2.20, p = 0.01, HR 3.97, p < 0.001) and OS (HR 2.25, p = 0.005, HR 3.95, p < 0.001). In RARC-ION patients, Trifecta rate was 64.1%. One-year day- and night-time continence rates were 78.6% and 48.3%. Age (HR 0.98, p = 0.03), female gender (HR 0.57, p = 0.008) and complications Clavien grade ≥ 3 (HR 0.55, p = 0.03) were identified as independent predictors of day-time incontinence. Conclusions: Long-term oncologic outcomes and their predicting factors seem aligned to the largest historical open series and multi-institutional robotic series data. According to the identified predicting factors undermining a proper achievement of day-time continence, this represents an objective support, in order to properly advice specific sub-group of patients
