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Kinnear N, Fonseca PC, Ogbechie C, Adam S, Haidar O, Jinaraj A, O'Callaghan M, Agarwal S, Lane T, Vasdev N, Adshead J. Impact of frozen section on long-term outcomes in robot-assisted laparoscopic prostatectomy. BJU Int 2024; 134:608-614. [PMID: 38961710 DOI: 10.1111/bju.16437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To compare 1-year functional and 5-year oncological outcomes of men undergoing robot-assisted laparoscopic prostatectomy (RALP) with neurovascular structure-adjacent frozen-section examination (NeuroSAFE) with those in men undergoing RALP without NeuroSAFE (standard of care [SOC]). SUBJECTS AND METHODS Men undergoing RALP in our centre between 1 January 2009 and 30 June 2018 were enrolled from a prospectively maintained database. Patients were excluded if they had undergone preoperative therapy or postoperative adjuvant therapy or were enrolled in clinical trials. Patients were grouped based on use of NeuroSAFE. Follow-up was censored at 5 years. The primary outcome was difference in time to biochemical recurrence (BCR) on multivariable analysis, defined as prostate-specific antigen (PSA) >0.2 ng/L on two consecutive measurements. Secondary outcomes were difference in 1-year erectile dysfunction and incontinence. RESULTS In the enrolment period, 1199 consecutive men underwent RALP, of whom 1140 were eligible, including 317 with NeuroSAFE and 823 with SOC. The median PSA follow-up was 60 months in both groups. Rates of 5-year BCR were similar on Kaplan-Meier survival curve analysis (11% vs 11%; P = 0.9), as was time to BCR on multivariable Cox proportional hazards modelling (hazard ratio 1.2; P = 0.6). Compared with the SOC group at 1 year, the NeuroSAFE group had similar unadjusted rates of incontinence (5.1% vs 7.7%) and lower unadjusted impotence (57% vs 80%). On multivariable analysis, NeuroSAFE patients had equivalent risk of incontinence (odds ratio [OR] 0.59, 95% CI 0.17-1.6; P = 0.4) but significantly reduced risk of erectile dysfunction (OR 0.37, 95% CI 0.22-0.60; P < 0.001). CONCLUSIONS For men undergoing RALP, compared with SOC, NeuroSAFE patients had equivalent time to BCR and risk of 1-year incontinence, and significantly lower risk of 1-year erectile dysfunction.
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Affiliation(s)
- Ned Kinnear
- Lister Hospital, Stevenage, UK
- Flinders Medical Centre, Adelaide, SA, Australia
| | | | | | | | | | | | - Michael O'Callaghan
- Flinders Medical Centre, Adelaide, SA, Australia
- Flinders University, Adelaide, SA, Australia
| | - Samita Agarwal
- Department of Histopathology, Lister Hospital, Stevenage, UK
| | | | - Nikhil Vasdev
- Lister Hospital, Stevenage, UK
- University of Hertfordshire, Hatfield, UK
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Freitas PFS, Blachman-Braun R, Soodana-Prakash N, Williams AD, Ritch CR, Punnen S, Gonzalgo ML, Parekh D, Nahar B. Changing times: trends in risk classification, tumor upstaging, and positive surgical margins after radical prostatectomy - results from a contemporary National Cancer Database study. World J Urol 2024; 42:551. [PMID: 39347950 PMCID: PMC11442602 DOI: 10.1007/s00345-024-05262-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 09/04/2024] [Indexed: 10/01/2024] Open
Abstract
PURPOSE Recent advancements in screening, prostate MRI, robotic surgery, and active surveillance have influenced the profile of patients undergoing radical prostatectomy (RP). We sought to examine their impact on trends in clinicodemographic, risk classification, and adverse pathology in men undergoing surgery. METHODS We queried the National Cancer Database for clinicodemographic, risk group, and pathology data in men undergoing upfront RP between 2006 and 2020. Patients were categorized by NCCN risk groups, and trends were assessed among 2006-2010, 2011-2015, and 2016-2020 periods. Endpoints included rates of pT3, positive surgical margins (PSM), pathologic upstaging, and Gleason grade group (GG) upgrading. RESULTS 610,762 patients were included. There were significant increases in African Americans (9.8-14.1%), comorbidities (2.1-5.2% with Charlson scores > 1), and robot-assisted RP (78-84%). Over the three time periods, high-risk cases increased from 15 to 20 to 27%, and intermediate-risk from 54 to 51 to 60%. Overall rates of pT3 rose from 20 to 38%, and PSM from 20 to 27% (p < 0.001). Pathologic upstaging increased in low (6-15%), intermediate (20-33%), and high-risk groups (42-58%) -p < 0.001. Gleason upgrading rose in low-risk (45-59%, p < 0.001), with slight reductions in the intermediate and high-risk groups. CONCLUSIONS Recent trends in RP indicate a shift towards more advanced disease, evidenced by increasing rates of pT3, PSM, and pathologic upstaging across all NCCN risk groups. These findings emphasize the need for a careful balance in applying fascia and nerve-sparing techniques to avoid compromising oncological safety.
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Affiliation(s)
- Pedro F S Freitas
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, 1120 NW 14th St. Miami, Miami, FL, 33136, USA.
| | - Ruben Blachman-Braun
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, 1120 NW 14th St. Miami, Miami, FL, 33136, USA
| | - Nachiketh Soodana-Prakash
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, 1120 NW 14th St. Miami, Miami, FL, 33136, USA
| | - Adam D Williams
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, 1120 NW 14th St. Miami, Miami, FL, 33136, USA
| | - Chad R Ritch
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, 1120 NW 14th St. Miami, Miami, FL, 33136, USA
| | - Sanoj Punnen
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, 1120 NW 14th St. Miami, Miami, FL, 33136, USA
| | - Mark L Gonzalgo
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, 1120 NW 14th St. Miami, Miami, FL, 33136, USA
| | - Dipen Parekh
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, 1120 NW 14th St. Miami, Miami, FL, 33136, USA
| | - Bruno Nahar
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, 1120 NW 14th St. Miami, Miami, FL, 33136, USA
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Armstrong M, Lu P, Wang J, El-Hayek K, Cleary S, Asbun H, Alseidi A, Tran Cao HS, Wei AC. Advancing minimally invasive hepato-pancreato-biliary surgery: barriers to adoption and equitable access. Surg Endosc 2024:10.1007/s00464-024-11078-1. [PMID: 39117957 DOI: 10.1007/s00464-024-11078-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/09/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Despite a growing body of literature supporting the safety of robotic hepatopancreatobiliary (HPB) procedures, the adoption of minimally invasive techniques in HPB surgery has been slow compared to other specialties. We aimed to identify barriers to implementing robotic assisted surgery (RAS) in HPB and present a framework that highlights opportunities to improve adoption. METHODS A modified nominal group technique guided by a 13-question framework was utilized. The meeting session was guided by senior authors, and field notes were also collected. Results were reviewed and free text responses were analyzed for major themes. A follow-up priority setting survey was distributed to all participants based on meeting results. RESULTS Twenty three surgeons with varying robotic HPB experience from different practice settings participated in the discussion. The majority of surgeons identified operating room efficiency, having a dedicated operating room team, and the overall hospital culture and openness to innovation as important facilitators of implementing a RAS program. In contrast, cost, capacity building, disparities/risk of regionalization, lack of evidence, and time/effort were identified as the most significant barriers. When asked to prioritize the most important issues to be addressed, participants noted access and availability of the robot as the most important issue, followed by institutional support, cost, quality of supporting evidence, and need for robotic training. CONCLUSIONS This study reports surgeons' perceptions of major barriers to equitable access and increased implementation of robotic HPB surgery. To overcome such barriers, defining key resources, adopting innovative solutions, and developing better methods of collecting long term data should be the top priorities.
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Affiliation(s)
- Misha Armstrong
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Pamela Lu
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jane Wang
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Kevin El-Hayek
- Department of Surgery, MetroHealth System, Cleveland, OH, USA
| | - Sean Cleary
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Horacio Asbun
- Department of Surgery, Baptist Health Miami Cancer Institute, Miami, FL, USA
| | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alice C Wei
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-886A, New York, NY, 10065, USA.
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Trecarten S, Bhandari M, Abdelaziz A, Noel O, Liss M, Dursun F, Svatek R, Mansour AM. Open versus minimally invasive nephroureterectomy in octogenarians: An analysis of surgical approach trends, outcomes, and survival analysis with propensity matching. Urol Oncol 2024; 42:220.e9-220.e19. [PMID: 38631967 DOI: 10.1016/j.urolonc.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/07/2024] [Accepted: 02/18/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Upper tract urothelial carcinoma (UTUC) is a rare disease accounting only for 5%-10% of urothelial carcinoma (UC). For localized high-risk disease, radical nephroureterectomy (RNU) is the standard of care. While minimally invasive (MIS) RNU has not been shown to decisively improve overall survival (OS) compared to open surgery, MIS RNU has been associated with reduced hospital length of stay (LOS), blood transfusion requirements and improved recovery, which are important considerations when treating older patients. The purpose of this study is to examine trends in surgical approach selection and outcomes of open vs. MIS RNU in patients aged ≥80 years. METHODS Using the National Cancer Database (NCDB), patients aged ≥80 years who underwent open or MIS (either robotic or laparoscopic) RNU were identified from 2010 to 2019. Demographic, patient-related, and disease-specific factors associated with either open or MIS RNU were assessed using multivariate logistic regression models. Survival analysis was conducted using Kaplan-Meier plots and Cox-proportional hazard regression. Inverse probability of treatment weighting (IPTW) was utilized to adjust for confounding variables. Survival analysis was also conducted on the IPTW adjusted cohort using Kaplan-Meier plots and Cox-proportional hazard regression. RESULTS 5,687 patients were identified, with 1,431 (25.2%) and 4,256 (74.8%) patients undergoing open and MIS RNU respectively. The proportion of RNU performed robotically has increased from 12.5% in 2010 to 50.4% in 2019. MIS was associated with a shorter hospital LOS (4.7 days versus 5.9 days, SMD 23.7%). Multivariate analysis revealed that MIS was associated with a significant reduction in 90-day mortality (OR: 0.571; 95%CI: 0.34-0.96, P = 0.033) and improved median OS (53.8 months [95%CI: 50.9-56.9] vs 42.35 months [95%CI: 38.6-46.8], P < 0.001) compared to open surgery. IPTW-adjusted survival analysis revealed improved median OS with MIS when compared to open surgery, with a survival benefit of 46.1 months (95%CI: 40.2-52.4 months) versus 37.7 months (95%CI: 32.6-46.5 months, P = 0.0034) respectively. IPTW-adjusted cox proportional hazard analysis demonstrated that MIS was significantly associated with reduced mortality (HR 0.76, 95%CI: 0.66-0.87, P < 0.001). CONCLUSION In octogenarians undergoing RNU, MIS is associated with improved median OS and 90-day mortality.
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Affiliation(s)
- Shaun Trecarten
- Department of Urology, UT Health San Antonio, San Antonio, TX
| | - Mukund Bhandari
- Department of Population Health Sciences, UT Health San Antonio, San Antonio, TX
| | - Ahmad Abdelaziz
- Department of Urology, UT Health San Antonio, San Antonio, TX
| | - Onika Noel
- Department of Urology, UT Health San Antonio, San Antonio, TX
| | - Michael Liss
- Department of Urology, UT Health San Antonio, San Antonio, TX; UT Health San Antonio/MD Anderson Mays Cancer Center, San Antonio, TX
| | - Furkan Dursun
- Department of Urology, UT Health San Antonio, San Antonio, TX; UT Health San Antonio/MD Anderson Mays Cancer Center, San Antonio, TX
| | - Robert Svatek
- Department of Urology, UT Health San Antonio, San Antonio, TX; UT Health San Antonio/MD Anderson Mays Cancer Center, San Antonio, TX
| | - Ahmed M Mansour
- Department of Urology, UT Health San Antonio, San Antonio, TX; UT Health San Antonio/MD Anderson Mays Cancer Center, San Antonio, TX; Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
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Pinci MV, Torres-Lugo NJ, Deliz-Jimenez DE, Salem-Hernandez J, Claudio-Marcano A, Ramírez N, Otero-López A. Patient Perception of Robotic-Assisted Total Joint Arthroplasty in a Hispanic Population. Arthroplast Today 2024; 25:101286. [PMID: 38292146 PMCID: PMC10826131 DOI: 10.1016/j.artd.2023.101286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/25/2023] [Accepted: 11/03/2023] [Indexed: 02/01/2024] Open
Abstract
Background Robotic-assisted orthopaedic surgery has become popular and widely available, mainly for total joint arthroplasty. However, there has been a persistent concern regarding access to robotic-assisted surgery and the utilization rate of total joint arthroplasty among minority groups. As an imperative effort to close the gap regarding health inequalities, we assessed the knowledge and perspective of Hispanics regarding robotic-assisted orthopaedic surgery. Methods A 28-item questionnaire was established to evaluate Hispanics' perceptions of robotic-assisted orthopaedic surgery. Participants answered questions about demographic features, knowledge about robotic-assisted orthopaedic surgery, and preferences regarding manual vs robotic-assisted procedures. Results A total of 580 questionnaires were analyzed in our study, with an average age of participants of 49.1 years. Only 44.2% of the participants were familiar with robotic-assisted orthopaedic surgery. Fifty-three percent of the respondents preferred robotic-assisted surgery over conventional procedures, with many participants believing that robotic-assisted surgery leads to better outcomes (54.7%) and faster recovery (53.1%). Conclusions Knowledge about specific factors such as clinical outcomes and costs may influence the perception and preference of Hispanics toward robotic-assisted orthopaedic surgery. Therefore, patient education may play a crucial role in the informed decision-making process in Hispanics when opting between robotic-assisted or traditional orthopaedic surgery.
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Affiliation(s)
- Marcantonio V. Pinci
- Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Norberto J. Torres-Lugo
- Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - David E. Deliz-Jimenez
- Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | | | - Alexandra Claudio-Marcano
- Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Norman Ramírez
- Department of Orthopaedic Surgery, Mayagüez Medical Center, Mayagüez, Puerto Rico
| | - Antonio Otero-López
- Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
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May M, Gilfrich C, Löbig N, Schnabel M, Wolff I. Impact of patients' health insurance status on the type of radical prostatectomy for localized prostate cancer in Germany: An observational analysis based on the multicentric IMPROVE study. J Surg Oncol 2024; 129:447-448. [PMID: 37942719 DOI: 10.1002/jso.27489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Matthias May
- Department of Urology, St. Elisabeth Hospital Straubing, Brothers of Mercy Hospital, Straubing, Germany
| | - Christian Gilfrich
- Department of Urology, St. Elisabeth Hospital Straubing, Brothers of Mercy Hospital, Straubing, Germany
| | - Niklas Löbig
- Department of Urology, University Hospital Ulm, Ulm, Germany
| | - Marco Schnabel
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Ingmar Wolff
- Department of Urology, University Medicine Greifswald, Greifswald, Germany
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Rabinowitz J, Kinnear N, O'Callaghan M, Hennessey D, Shafi F, Fuller A, Ibrahim M, Lane T, Adshead J, Vasdev N. Systematic review of the ophthalmic complications of robotic-assisted laparoscopic prostatectomy. J Robot Surg 2024; 18:46. [PMID: 38240959 DOI: 10.1007/s11701-023-01771-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024]
Abstract
This study aims to review ophthalmic injuries sustained during of robotic-assisted laparoscopic prostatectomy (RALP). A search of Medline, Embase, Cochrane and grey literature was performed using methods registered a priori. Eligible studies were published 01/01/2010-01/05/2023 in English and reported ophthalmic complications in cohorts of > 100 men undergoing RALP. The primary outcome was injury incidence. Secondary outcomes were type and permanency of ophthalmic complications, treatments, risk factors and preventative measures. Nine eligible studies were identified, representing 100,872 men. Six studies reported rates of corneal abrasion and were adequately homogenous for meta-analysis, with a weighted pooled rate of 5 injuries per 1000 procedures (95% confidence interval 3-7). Three studies each reported different outcomes of xerophthalmia, retinal vascular occlusion, and ophthalmic complications unspecified in 8, 5 and 2 men per 1000 procedures respectively. Amongst identified studies, there were no reports of permanent ophthalmic complications. Injury management was poorly reported. No significant risk factors were reported, while one study found African-American ethnicity protective against corneal abrasion (0.4 vs. 3.9 per 1000). Variables proposed (but not proven) to increase risk for corneal abrasion included steep Trendelenburg position, high pneumoperitoneum pressure, prolonged operative time and surgical inexperience. Compared with standard of care, occlusive eyelid dressings (23 vs. 0 per 1000) and foam goggles (20 vs. 1.3 per 1000) were found to reduce rates of corneal abrasion. RALP carries low rates of ophthalmic injury. Urologists should counsel the patient regarding this potential complication and pro-actively implement preventative strategies.
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Affiliation(s)
| | - Ned Kinnear
- Lister Hospital, Coreys Mill Ln, Stevenage, SG1 4AB, UK.
- Flinders Medical Centre, Adelaide, Australia.
| | - Michael O'Callaghan
- Flinders Medical Centre, Adelaide, Australia
- Flinders University, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
| | | | - Fariha Shafi
- Lister Hospital, Coreys Mill Ln, Stevenage, SG1 4AB, UK
| | | | | | - Timothy Lane
- Lister Hospital, Coreys Mill Ln, Stevenage, SG1 4AB, UK
| | - James Adshead
- Lister Hospital, Coreys Mill Ln, Stevenage, SG1 4AB, UK
| | - Nikhil Vasdev
- Lister Hospital, Coreys Mill Ln, Stevenage, SG1 4AB, UK
- University of Hertfordshire, Hatfield, UK
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Hays SB, Corvino G, Lorié BD, McMichael WV, Mehdi SA, Rieser C, Rojas AE, Hogg ME. Prince and princesses: The current status of robotic surgery in surgical oncology. J Surg Oncol 2024; 129:164-182. [PMID: 38031870 DOI: 10.1002/jso.27536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 12/01/2023]
Abstract
Robotic surgery has experienced a dramatic increase in utilization across general surgery over the last two decades, including in surgical oncology. Although urologists and gynecologists were the first to show that this technology could be utilized in cancer surgery, the robot is now a powerful tool in the treatment of gastrointestinal, hepato-pancreatico-biliary, colorectal, endocrine, and soft tissue malignancies. While long-term outcomes are still pending, short-term outcomes have showed promise for this technologic advancement of cancer surgery.
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Affiliation(s)
- Sarah B Hays
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Gaetano Corvino
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Benjamin D Lorié
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - William V McMichael
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Syed A Mehdi
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Caroline Rieser
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Aram E Rojas
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Melissa E Hogg
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
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