Faculty Bibliography

INTRODUCTION:We sought to compare surgical outcomes between transperitoneal and retroperitoneal robotic partial nephrectomy (RPN) for posterior tumors. PATIENTS AND METHODS:Using our multi-institutional RPN database, we reviewed 610 consecutive cases for posterior renal masses treated between 2007 and 2015. Primary outcomes were complications, operative time, length of stay (LOS), surgical margin status, and estimated glomerular filtration rate (eGFR) preservation. Secondary outcomes were estimated blood loss, warm ischemia time (WIT), disease recurrence, and disease-specific mortality. Due to significant differences in treatment year and tumor size between approaches, retroperitoneal cases were matched 1:4 to transperitoneal cases based on propensity scores using the greedy algorithm. Outcomes were compared between approaches using the chi-square and Mann-Whitney U tests. RESULTS:After matching, 296 transperitoneal and 74 retroperitoneal cases were available for analysis, and matched groups were well balanced in terms of treatment year, age, gender, race, American Society of Anesthesiologists physical status classification (ASA) score, body mass index, tumor laterality, tumor size, R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus, anterior/posterior, location relative to polar lines) score, and hilar location. Compared with transperitoneal, the retroperitoneal approach was associated with significantly shorter mean LOS (2.2 vs 2.6 days, p = 0.01), but longer mean WIT (21 vs 19 minutes, p = 0.01). Intraoperative (p = 0.35) and postoperative complications (p = 0.65), operative time (p = 0.93), positive margins (p = 1.0), and latest eGFR preservation (p = 0.25) were not significantly different between approaches. No differences were detected in the other outcomes. CONCLUSIONS:Among high-volume surgeons, transperitoneal and retroperitoneal RPN achieved similar outcomes for posterior renal masses, although with slight differences in LOS and WIT. Retroperitoneal RPN may be an effective option for the treatment of certain small posterior renal masses.

Purpose Pre-operative three-dimensional (3D) printed renal malignancy models are tools with potential benefits in surgical training and patient education [1,2]. Most importantly, 3D models may facilitate surgical planning by allowing surgeons to assess tumor complexity as well as the relationship of the tumor to major anatomic structures [3]. The objective of this study was to evaluate this impact. Methods Imaging was obtained from an IRB approved, prospectively collected database of multiparametric magnetic resonance imaging (MRI) of renal masses. Ten cases eligible for elective partial nephrectomy were retrospectively selected. High-fidelity models were 3D printed in multiple colors based on T1 images (Fig. 1). Cases were reviewed by three attending surgeons and six senior residents with imaging alone and in addition to the 3D model. A standardized questionnaire was developed to capture the planned surgical approach and intraoperative technique in both sessions. Results Surgical approach was changed in 20 % of decisions, intraoperative considerations were changed in 40 % (Fig. 2). Thirty percent and 23 % of decisions in the attending and resident groups, respectively, were altered by the 3D model. Overall, every case was modified with this additional information. All participants reported that the models helped plan the surgical approach for partial nephrectomy. Most reported improved comprehension of anatomy and confidence in surgical plan. Half reported that the 3D printed model altered their surgical plan significantly. Due to use of T1 images, reconstruction of calyces and tertiary blood vessels were limited: 8 of the 9 participants desired more information regarding these structures. (Figure presented) Conclusion Utilization of 3D modeling may aid in pre-operative and intra-operative planning for both attending and resident surgeons. While 3D models with MR imaging is feasible, computed tomography (CT) imaging may provide additional anatomical information. Future study is required to prospectively assess the utility of models and pre-operative planning and intra-operative guidance

BACKGROUND: The uptake of robotic surgery has led to changes in potential operative complications, as many surgeons learn minimally invasive surgery, and has allowed the documentation of such complications through the routine collection of intraoperative video. OBJECTIVE: We documented intraoperative complications from robot-assisted radical prostatectomy (RARP) with the aim of reporting the mechanisms, etiology, and necessary steps to avoid them. Our goal was to facilitate learning from these complications to improve patient care. DESIGN, SETTING, AND PARTICIPANTS: Contributors delivered videos of complications that occurred during laparoscopic and robotic prostatectomy between 2010 and 2015. SURGICAL PROCEDURE: Surgical footage was available for a variety of complications during RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Based on these videos, a literature search was performed using relevant terms (prostatectomy, robotic, complications), and the intraoperative steps of the procedures and methods of preventing complications were outlined. RESULTS AND LIMITATIONS: As a major surgical procedure, RARP has much potential for intra- and postoperative complications related to patient positioning, access, and the procedure itself. However, with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, we suggest that the majority of such complications are preventable. CONCLUSIONS: Considering the complexity of the procedure, RARP is safe and reproducible for the surgical management of prostate cancer. Insight from experienced surgeons may allow surgeons to avoid complications during the learning curve. PATIENT SUMMARY: Robot-assisted radical prostatectomy has potential for intra- and postoperative complications, but with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, most complications are preventable.

OBJECTIVES: to evaluate the incidence of and risk factors for a urine leak in a large multicenter, prospective database of robotic partial nephrectomy (rpn). PATIENTS AND METHODS: a database of 1791 rpn from five centers was reviewed for urine leak as a complication of rpn. patients with postoperative urine leaks were compared to patients without postoperative urine leaks on a variety of patient and tumor characteristics. fisher's exact test was used for qualitative variables and wilcoxon sum-rank tests were used for quantitative variables. a review of the literature on partial nephrectomy and urine leak was conducted. RESULTS: urine leak was noted in 14/1791 (0.78%) patients who underwent rpn. mean nephrometry score of the entire cohort was 7.2 +/- 1.9, and 8.0 +/- 1.9 in patients who developed urine leak. the median postoperative day of presentation was 13 (range 3-32). patients with urine leak presented in delayed fashion with fever (14%), gastrointestinal complaints (29%), and pain (36%). eight patients required admission (57%), while eight (57%) and nine (64%) had a drain or stent placed, respectively. drains and stents were removed after a median of eight (range 4-13) and 21 days (8-83), respectively. variables associated with urine leak included tumor size (p = 0.021), hilar location (p = 0.025), operative time (p=0.006), warm ischemia time (p = 0.005), and pelvicaliceal repair (p = 0.018). upon literature review, the historical incidence of leak ranged from 1.0-17.4% for opn and 1.6-16.5% for lpn. CONCLUSION: the incidence of urine leak after rpn is very low and may be predicted by some preoperative factors, affording better patient counseling of risks. the low urine leak may be attributed to the enhanced visualization and suturing technique that accompanies the robotic approach

INTRODUCTION: There is increasing interest in using imaging in the detection and localization of prostate cancer (PCa). Both multiparametric magnetic resonance imaging (mpMRI) and HistoScanning (HS) have been independently evaluated in the detection and localization of PCa. We undertook a prospective, blinded comparison of mpMRI and HS for cancer localization among men undergoing radical prostatectomy. METHODS: Following approval by the institutional review board, men scheduled to undergo radical prostatectomy, who had previously undergone mpMRI at our institution, were offered inclusion in the study. Those consenting underwent preoperative HS following induction of anesthesia; mpMRI, HS, and surgical step-section pathology were independently read by a single radiologist, urologist, and pathologist, respectively, in a blinded fashion. Disease maps created by each independent reader were compared and evaluated for concordance by a 5 persons committee consisting of 2 urologists, 2 pathologists, and 1 radiologist. Logistic regression for correlated data was used to assess and compare mpMRI and HS in terms of diagnostic accuracy for cancer detection. Generalized estimating equations based on binary logistic regression were used to model concordance between reader opinion and the reference standard assessment of the same lesion site or region as a function of imaging modality. RESULTS: Data from 31/35 men enrolled in the trial were deemed to be evaluable. On evaluation of cancer localization, HS identified cancer in 36/78 (46.2%) regions of interest, as compared with 41/78 (52.6%) on mpMRI (P = 0.3968). The overall accuracy, positive predictive value, negative predictive value, and specificity for detection of disease within a region of interest were significantly better with mpMRI as compared with HS. HS detected 36/84 (42.9%) cancer foci as compared with 42/84 (50%) detected by mpMRI (P = 0.3678). Among tumors with Gleason score>6, mpMRI detected 19/22 (86.4%) whereas HS detected only 11/22 (50%, P = 0.0078). Similarly, among tumors>10mm in maximal diameter, mpMRI detected 28/34 (82.4%) whereas HS detected only 19/34 (55.9%, P = 0.0352). CONCLUSION: In our institution, the diagnostic accuracy of HS was inferior to that of mpMRI in PCa for PCa detection and localization. Although our study warrants validation from larger cohorts, it would suggest that the HS protocol requires further refinement before clinical implementation.

Introduction & Objective: The management of concurrent ipsilateral ureteral strictures is challenging as the ureter cannot be transected in two places. The mainstays of reconstruction in this clinical scenario include renal autotransplant or ileal ureter, both of which are associated with morbid short and long-term complications. The concept of an onlay graft or flap to increase the size of the lumen is a well-established technique for urethral reconstruction. We demonstrate the feasibility of this concept to the ureter by placing an onlay of bladder and appendix to manage concurrent ureteral strictures. Materials and Methods: A 66-year-old man with bilateral proximal ureteral stones who developed a 3 cm right distal ureteral stricture, and a 6 cm right proximal ureteral after undergoing ureteroscopy and laser lithotripsy at an outside institution. These strictures were refractory to endoscopic management. The patient had an elevated creatinine. Robotic reconstruction was performed. Simultaneous intraoperative ureteroscopy was performed to delineate the stricture. As the ureteroscope was passed retrograde, the 3 cm distal and 6 cm proximal ureteral strictures were incised using the robot along the anterior aspect of the ureter. The patient's appendix was mobilized, detubularized, and placed as an onlay flap onto the proximal stricture. The distal ureteral stricture was repaired by marsupializing a flap of bladder onto the ureter for a non-transecting reimplant. Results: The patient had an uneventful postoperative course and went home on postoperative day 4. Nephrostogramperformed at 6 weeks post op demonstrated prompt drainage of contrast after stent removal. Patient did not have flank pain after stent removal, and ultrasound at 4 months post op demonstrated no hydronephrosis. Conclusions: For the appropriate patient, ureteral reconstruction using onlay of appendix and bladder is a feasible option for multiple ureteral strictures. Long-term outcomes need to be elucidated

OBJECTIVE: To evaluate our long-term outcomes of robotic assisted laparoscopic (RAL) upper urinary tract (UUT) reconstruction. MATERIALS AND METHODS: Data from 250 consecutive patients undergoing RAL UUT reconstruction including pyeloplasty with or without stone extraction, ureterolysis, ureteroureterostomy, ureterocalicostomy, ureteropyelostomy, ureteral reimplantation and buccal mucosa graft ureteroplasty was collected at a tertiary referral center between March 2003 and December 2013. The primary outcomes were symptomatic and radiographic improvement of obstruction and complication rate. The mean follow-up was 17.1 months. RESULTS: Radiographic and symptomatic success rates ranged from 85% to 100% for each procedure with a 98% radiographic success rate and 97% symptomatic success rate for the entire series. There were a total of 34 complications; none greater than Clavien grade 3. CONCLUSION: RAL UUT can be performed with few complications, with durable long-term success, and is a reasonable alternative to the open procedure in experienced robotic surgeons

OBJECTIVE: To describe the technique of robotic buccal mucosa graft ureteroplasty as a minimally invasive alternative method of ureteral reconstruction for proximal or multifocal ureteral strictures not amenable to primary anastomosis. METHODS: Between October 2013 and May 2014, we performed robotic assisted ureteral reconstruction using buccal mucosa grafts in four patients (mean age 41.5, range 23-67). The indication for surgery was a proximal or multifocal stricture not amenable to ureteroureterostomy or ureteropyelostomy. Buccal mucosa grafts were harvested to be the length of the strictured segment and 1cm in width and placed in the ureter as an anterior or posterior onlay. Follow up was performed with diuretic renogram at least 3 months post operatively and renal ultrasound as well as clinical assessment of symptoms. RESULTS: All four patients underwent successful robotic assisted reconstruction of the ureter using buccal mucosa graft. There were no intraoperative complications. At a median follow up of 15.5 months (range 10.7 to 18.6), there has been 100% success. CONCLUSIONS: Robotic buccal mucosa graft ureteroplasty is a feasible option for reconstruction of proximal or multifocal ureteral strictures that are not amenable to primary anastomosis, and it avoids the morbidity of alternative procedures.

OBJECTIVE: To compare the perioperative outcomes of robotic partial nephrectomy (RPN) with laparoscopic PN (LPN) performed for small renal masses (SRMs), in a large multi-institutional series and to define a new composite outcome measure, termed 'optimal outcome' for the RPN group. PATIENTS AND METHODS: Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high-volume centres from 2004 to mid-2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of