Full Neurovascular Sparing Extraperitoneal Robotic Radical Prostatectomy: Our Experience with PERUSIA Technique

Effects of different surgical modalities for nerve-sparing robot-assisted radical prostatectomy on postoperative erectile function: a systematic review and one-arm meta-analysis

Maintaining erectile function is an important quality of life issue for patients with localized prostate cancer treated with robotic-assisted radical prostatectomy (RARP). However, most existing studies are retrospective and inherently weak and cannot conclude which NS approach is most effective in restoring function in patients. We therefore performed a consistent and objective assessment of sexual function outcomes in RARP using different nerve-sparing methods to optimize postoperative outcomes. A systematic review and meta-analysis was performed based on PRISMA and STROBE statement criteria. Statistical analysis was performed using StataMP software version 14. The Newcastle-Ottawa scale was used to assess the risk of bias. This single-arm meta-analysis included 3 randomized controlled trials and 14 cohort studies with a total of 3756 patients. Our meta-analysis found that patients had the highest efficiency rate of 0.86 (0.78, 0.93) after the NS technique using the retrograde method. Overall, there are significant differences between RARP NS techniques and outcomes, and the ideal technical strategy to optimize outcomes remains controversial. However, there is consensus on the importance of careful separation, dissection of the NVB, reduction of traction and thermal injury, and preservation of the fascia around the prostate. We still need more well-designed randomized controlled trials with videos describing the details of the different surgical techniques before they can be replicated.

Surgical techniques to preserve continence after robot-assisted radical prostatectomy

Radical prostatectomy significantly impacts the inherent anatomy of the male pelvis and the functional mechanisms of urinary continence. Incontinence has a considerable negative influence on the quality of life of patients, as well as their social and psychological wellbeing. Numerous surgical techniques have been demonstrated to support the preservation of continence during robot-assisted radical prostatectomy (RARP). In this in-depth analysis, we give a general summary of the surgical techniques used in RARP and their impact on incontinence rates.

Robot-assisted radical cystectomy with intracorporeal reconstruction of urinary diversion by mechanical stapler: prospective evaluation of early and late complications

Introduction

Radical cystectomy with pelvic lymph node dissection is the gold standard treatment for non-metastatic muscle-invasive bladder cancer and high-risk non-muscle-invasive bladder cancer. For years, the traditional open surgery approach was the only viable option. The widespread of robotic surgery led to its employment also in radical cystectomy to reduce complication rates and improve functional outcomes. Regardless of the type of approach, radical cystectomy is a procedure with high morbidity and not negligible mortality. Data available in the literature show how the use of staplers can offer valid functional outcomes, with an acceptable rate of complications shortening the operative time. The aim of our study was to describe the perioperative outcomes and complications associated with robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) using a mechanical stapler.

Material and methods

From January 2015 to May 2021, we enrolled patients who underwent RARC with pelvic node dissection and stapled ICUD (ileal conduit or ileal Y-shaped neobladder according to the Perugia ileal neobladder) in our high-volume center. Demographic features, perioperative outcomes and early (≤30 days) and late (>90 days) post-operative complications according to the Clavien-Dindo classification, were recorded for each patient. We also analyzed the potential linear correlation between demographic, pre-operative as well as operative features and the risk of post-operative complications.

Results

Overall, 112 patients who underwent RARC with ICUD were included with a minimum follow-up of 12 months. Intracorporeal Perugia ileal neobladder was performed in 74.1% of cases while ileal conduit was performed in 25.9%. The mean operative time, estimated intraoperative blood loss, and LOS were 289.1 ± 59.7 min, 390.6 ± 186.2 ml, and 17.5 ± 9.8 days, respectively. Early minor and major complications accounted for 26.7% and 10.8%, respectively. Overall late complications were 40.2%. The late most common complications were hydronephrosis (11.6%) and urinary tract infections (20.5%). Stone reservoir formation occurred in 2.7% of patients. Major complications occurred in 5.4%. In the sub-analysis, the mean operative time and the estimated blood loss improved significantly from the first 56 procedures to the last ones.

Conclusion

RARC with ICUD performed by mechanical stapler is a safe and effective technique. Stapled Y-shaped neobladder did not increase the complication rate.

Complications of extraperitoneal robot-assisted radical prostatectomy in high-risk prostate cancer: A single high-volume center experience

Introduction

The role of robot-assisted radical prostatectomy (RARP) in high-risk prostate cancer (PCa) has been debated over the years, but it appears safe and effective in selected patients. While the outcomes of transperitoneal RARP for high-risk PCa have been already widely investigated, data on the extraperitoneal approach are scarcely available. The primary aim of this study is to evaluate intra- and postoperative complications in a series of patients with high-risk PCa treated by extraperitoneal RARP (eRARP) and pelvic lymph node dissection. The secondary aim is to report oncological and functional outcomes.

Methods

Data of patients who underwent eRARP for high-risk PCa were prospectively collected from January 2013 to September 2021. Intraoperative and postoperative complications were recorded, as also perioperative, functional, and oncological outcomes. Intraoperative and postoperative complications were classified by employing Intraoperative Adverse Incident Classification by the European Association of Urology and the Clavien–Dindo classification, respectively. Univariate and multivariate analyses were performed to evaluate a potential association between clinical and pathological features and the risk of complications.

Results

A total of 108 patients were included. The mean operative time and estimated blood loss were 183.5 ± 44 min and 115.2 ± 72.4 mL, respectively. Only two intraoperative complications were recorded, both grade 3. Early complications were recorded in 15 patients, of which 14 were of minor grade, and 1 was grade IIIa. Late complications were diagnosed in four patients, all of grade III. Body mass index (BMI) > 30 kg/m2, Prostate-Specific Antigen (PSA) > 20 ng/mL, PSA density >0.15 ng/mL2, and pN1 significantly correlated with a higher rate of overall postoperative complications. Moreover, BMI >30 kg/m2, PSA >20 ng/mL, and pN1 significantly correlated with a higher rate of early complications, while PSA >20 ng/mL, prostate volume <30 mL, and pT3 were significantly associated with a higher risk of late complications. In multivariate regression analysis, PSA >20 ng/mL significantly correlated with overall postoperative complications, while PSA > 20 and pN1 correlated with early complications. Urinary continence and sexual potency were restored in 49.1%, 66.7%, and 79.6% of patients and in 19.1%, 29.9%, and 36.2% of patients at 3, 6, and 12 months, respectively.

Conclusions

eRARP with pelvic lymph node dissection in patients with high-risk PCa is a feasible and safe technique, resulting in only a few intra- and postoperative complications, mostly of low grade.

Single-port robot-assisted perineal radical prostatectomy with the da Vinci XI system: initial experience and learning curve using the cumulative sum method

BACKGROUND

To evaluate the early functional and oncological outcomes of single-port robot-assisted perineal radical prostatectomy (sp-pRARP) using the da Vinci XI system and analyze its learning curve using the cumulative sum (CUSUM) method.

METHODS

The clinical data of 50 patients who underwent sp-pRARP for localized prostate cancer between May 2020 and May 2022 in our center by a single surgeon were analyzed retrospectively. Demographic information, preoperative and postoperative variables, complications, early functional and oncological outcomes of patients were recorded. The CUSUM method was used to illustrate the learning curve based on operation time.

RESULTS

All surgeries were completed without conversion. The median (interquartile range, IQR) operation time was 205.0 (82.5) min, whereas the median (IQR) docking time was 30.0 (15.0) min and the console time was 120.0 (80.5) min. The median (IQR) estimated blood loss (EBL) was 50.0 (137.5) mL. Positive surgical margins were detected in five patients (10.0%). The continence rate was 40.9%, 63.6%, 88.4%, and 97.7% at the 1, 3, 6, and 12 months after surgery. According to the CUSUM plot, the inflection points of the learning curve were 20 cases, splitting the case series into "early phase" and "late phase." In "late phase" cases, there was less time spent on each step of the operation and less EBL.

CONCLUSIONS

Sp-pRARP using the da Vinci XI system was verified to be a feasible and reliable surgical approach. According to the CUSUM plot, 20 cases was considered the turning point for surgeons to master the novel technique.

Urologic latency time during uroflow stop test with electromyography: an incontinence detector in rehabilitation after robotic radical prostatectomy

BACKGROUND

Stress urinary incontinence (UI) is the most common presentation following robot-assisted radical prostatectomy (RARP), but a postoperative non-invasive and objective test is still lacking. To assess pelvic floor integrity after RARP, we recently proposed Uroflow Stop Test (UST) with surface electromyography (EMG).

AIM

Here we provide two new clinical parameters: the neurologic latency time (NLT) and the urologic latency time (ULT) derived from UST-EMG Test. Principal outcome was to evaluate their variation during one year follow-up and ULT ability to predict post-RARP UI.

DESIGN

Observational and longitudinal study.

SETTING

Interdivisional Urology Clinic (Perugia-Terni, Italy).

POPULATION

Patients with prostate cancer treated with a full nerve-sparing RARP who underwent postoperative pelvic floor muscles training (PFMT): a diurnal functional home program and a weekly hospital program with the use of biofeedback, between 1 and 3 months postoperatively.

METHODS

All patients consecutively performed a UST-EMG test at one, three, six, and twelve months after surgery. At each follow-up visit we collected NLT values, ULT values, 5-item 26-Expanded Prostate Cancer Index (EPIC), Incontinence Developed on Incontinence Questionnaire (ICIQ-UI) Short Form and International Prostate Symptom Score (IPSS). We analysed statistically significant differences in NLT and ULT between continent and incontinent patients and we evaluate the diagnostic ability of 1-month post-surgery ULT value to diagnose the presence of postoperative UI.

RESULTS

Sixty patients were enrolled. The mean time to PFMT was 31.08 (range: 30-35) days. Overall IPSS, NLT and ULT had similar trends: progressive decrease until the six months after surgery (1-month vs. 3 months vs. 6 months, P<0.05) to plateau thereafter. When considering the two group of patients, IPSS and NLT were significantly higher in the incontinent group only one month after surgery, while ULT became similar between the two groups at 6 months after surgery. The best cut-off of 1-month ULT values that maximized the Youden function at 12-months resulted 3.13 second.

CONCLUSIONS

NLT and ULT may respectively account for the nerve and the urethral closure system integrity post-RARP. In the first month after RARP, both NLT and ULT differs between incontinent vs. continent patients. NLT become similar between two group after one month, confirming the recovery from neuropraxia, but ULT remains statistically significant different until 3 months postoperatively. The value of 1-month ULT resulted a valid tool to predict incontinence status at 12 months.

CLINICAL REHABILITATION IMPACT

ULT and NLT may be also useful tools to monitor the continence progressive recovery after RARP and they may help rehabilitation specialists to evaluate the ongoing results during postoperative follow-up.

Case report: Adrenal myelolipoma resected by laparoscopic surgery

Introduction

Adrenal myelolipomas are benign tumors composed mainly of lipomatous elements with myeloid cells. With the development of medical imaging technology, the detection rate has gradually increased. We report a case of adrenal myelolipoma successfully excised through the laparoscope and reviewed existing literature in recent ten years to summarize the feasibility of the laparoscopic approach for this tumor.

Case presentation

Herein, we described a case of adrenal myelolipoma resected by laparoscope in a 63-year-old male patient. He did not have any other symptoms except the incidental finding of a left adrenal mass. An abdominal CT examination revealed a mixed-density lesion containing some amount of adipose tissue. In conjunction with the patient's willingness, we performed a laparoscopic operation to remove the lump. The definite diagnosis was confirmed as an adrenal myelolipoma according to the pathology. The patient recovered well postoperatively and without signs of recurrence at a 5-month follow-up.

Conclusion

Adrenal myelolipoma is commonly benign, asymptomatic, and hormonal inactivity. A surgical strategy is suggested for high-complication-risk patients. The laparoscopic approach is safe and effective with an obvious advantage over open procedures.

Correlations between serum levels of microRNA-148a-3p and microRNA-485-5p and the progression and recurrence of prostate cancer

BACKGROUND

Unpredicted postoperative recurrence of prostate cancer, one of the most common malignancies among males worldwide, has become a prominent issue affecting patients after treatment. Here, we investigated the correlation between the serum miR-148a-3p and miR-485-5p expression levels and cancer recurrence in PCa patients, aiming to identify new biomarkers for diagnosis and predicting postoperative recurrence of prostate cancer.

METHODS

A total of 198 male PCa cases treated with surgery, postoperative radiotherapy, and chemotherapy were involved in the presented study. Serum levels of miR-148a-3p and miR-485-5p were measured before the initial operation for the involved cases, which were then followed up for two years to monitor the recurrence of cancer and to split the cases into recurrence and non-recurrence groups. Comparison of the relative expressions of serum miR-148a-3p and miR-485-5p were made and related to other clinic pathological features.

RESULTS

Pre-surgery serum levels of miR-148a-3p in patients with TNM stage cT1-2a prostate cancer (Gleason score < 7) were significantly lower (P < 0.05) than levels in patients with TNM Classification of Malignant Tumors (TNM) stage cT2b and higher prostate cancer (Gleason score ≥ 7). pre-surgery serum levels of miR-485-5p in patients with TNM stage cT1-2a prostate cancer (Gleason score < 7) were significantly higher (P < 0.05) than in patients with TNM stage cT2b and higher cancer (Gleason score ≥ 7). Serum miR-148a-3p level in recurrence group is higher than the non-recurrence group (P < 0.05) while serum miR-485-5p level in recurrence group is lower than non-recurrence group (P < 0.05). ROC curve analysis showed the AUCs of using miR-148a-3p, miR-485-5p, and combined detection for predicting recurrence of prostate cancer were 0.825 (95% CI 0.765-0.875, P < 0.0001), 0.790 (95% CI 0.726-0.844, P < 0.0001), and 0.913 (95% CI 0.865-0.948, P < 0.0001).

CONCLUSION

Pre-surgery serum miR-148a-3p level positively correlates while miR-485-5p level negatively correlates with prostate cancer's progressing and postoperative recurrence. Both molecules show potential to be used for predicting postoperative recurrence individually or combined.

Simultaneous treatment of a pubovesical fistula and lymph node metastasis secondary to multimodal treatment for prostate cancer: Case report and review of the literature

Pubovesical fistula (PVF) is a rare complication of radical treatments for prostate cancer (PCa), especially when a multimodal approach is performed. We present a case of PVF with extensive communication between the bladder and the pubic bones, and lymph node metastases of PCa treated by cystectomy and salvage lymphadenectomy. We describe a case of a 65-year old male patient who, after radical prostatectomy and adjuvant radiation therapy, suffered from suprapubic and perineal pain, ambulation difficulties and recurrent urinary tract infections. Cystoscopy, cystography and contrast-enhanced magnetic resonance imaging diagnosed a PVF. Choline positron emission tomography/computed tomography scan demonstrated PCa lymph node metastases. After the failure of conservative treatment, open radical cystectomy with ureterocutaneostomy diversion and salvage lymphadenectomy were performed with resolution of symptoms. At 3-month follow-up, the pelvic and perineal pain was completely regressed and 1-year later the patient was still asymptomatic. This clinical case shows efficacy and safety of combined salvage lymphadenectomy and cystectomy with urinary diversion for the treatment of late PCa node metastasis and PVF.

The Challenges of Patient Selection for Prostate Cancer Focal Therapy: A Retrospective Observational Multicentre Study

Increased diagnoses of silent prostate cancer (PCa) have led to overtreatment and consequent functional side effects. Focal therapy (FT) applies energy to a prostatic index lesion treating only the clinically significant PCa focus. We analysed the potential predictive factors of FT failure. We collected data from patients who underwent robot-assisted radical prostatectomy (RARP) in two high-volume hospitals from January 2017 to January 2020. The inclusion criteria were: one MRI-detected lesion with a Gleason Score (GS) of ≤7, ≤cT2a, PSA of ≤10 ng/mL, and GS 6 on a random biopsy with ≤2 positive foci out of 12. Potential oncological safety of FT was defined as the respect of clinicopathological inclusion criteria on histology specimens, no extracapsular extension, and no biochemical, local, or metastatic recurrence within 12 months. To predict FT failure, we performed uni- and multivariate logistic regression. Sixty-seven patients were enrolled. The MRI index lesion median size was 11 mm; target lesions were ISUP grade 1 in 27 patients and ISUP grade 2 in 40. Potential FT failure occurred in 32 patients, and only the PSA value resulted as a predictive parameter (p < 0.05). The main issue for FT is patient selection, mainly because of multifocal csPCa foci. Nevertheless, FT could represent a therapeutic alternative for highly selected low-risk PCa patients.

Rectourethral fistula following focal irreversible electroporation for prostate cancer

A man in his 50s presented 4-week postirreversible electroporation (IRE) for low-to-intermediate risk prostate cancer with urinary symptoms, diarrhoea and passing fluid per rectum when urinating. Urine microscopy and sensitivities showed raised leucocytes, erythrocytes and pansensitive Escherichia coli. A CT cystogram revealed a rectourethral fistula (RUF). Urinary diversion with insertion of an indwelling catheter for 6 weeks was performed. A rigid cystoscopy 6 weeks after urinary diversion revealed that the fistula was still present, confirmed by intraoperative contrast. The fistula was repaired with diathermy and a fibrin glue. The patient reported resolution of urinary and bowel symptoms. This is the first case report in the literature of an RUF following IRE for prostate cancer. It is important to report these rare complications as novel treatments become more common across the world.Background

Pro-Survival Factor EDEM3 Confers Therapy Resistance in Prostate Cancer

Prostate cancer is the most common cancer in men, and it is primarily driven by androgen steroid hormones. The glycosylation enzyme EDEM3 is controlled by androgen signalling and is important for prostate cancer viability. EDEM3 is a mannosidase that trims mannose from mis-folded glycoproteins, tagging them for degradation through endoplasmic reticulum-associated degradation. Here, we find that EDEM3 is upregulated in prostate cancer, and this is linked to poorer disease-free survival. Depletion of EDEM3 from prostate cancer cells induces an ER stress transcriptomic signature, and EDEM3 overexpression is cyto-protective against ER stressors. EDEM3 expression also positively correlates with genes involved in the unfolded protein response in prostate cancer patients, and its expression can be induced through exposure to radiation. Importantly, the overexpression of EDEM3 promotes radio-resistance in prostate cancer cells and radio-resistance can be reduced through depletion of EDEM3. Our data thus implicate increased levels of EDEM3 with a role in prostate cancer pathology and reveal a new therapeutic opportunity to sensitise prostate tumours to radiotherapy.

Endopelvic Fascia Sparing Robotic Radical Cystectomy with Intracorporeal Studer Pouch with Balbay's Technique

Background and Objectives

Robotic radical cystectomy (RARC) with intracorporeal urinary diversion is a technically complicated, time-consuming procedure. The aim of this study was to present the operative, pathological, oncological, and functional outcomes of patients who underwent endopelvic fascia sparing (EPFS) RARC with intracorporeal Studer pouch formation. To the best of our knowledge, this is first series in the literature that includes EPFS RARC.

Methods

Between October 1, 2019 and April 30, 2022, 10 bladder cancer patients underwent EPFS RARC, bilateral extended pelvic lymph node dissection with intracorporeal Studer pouch reconstruction with Balbay's technique. Patient demographics, operative, and post-operative parameters were recorded.

Results

Among 10 patients, 8 were male and 2 were female. Mean operative time, median estimated blood loss, and median duration of hospital stay was 530 minutes, 316 ml, and 8 days, respectively. One month postoperatively, the mean maximum flow, average flow rate, mean voided, and post-voided urine volume were 20.2 ml/sec, 4.4 ml/sec, 273.6 ml, and 3.5 ml, respectively. All of the patients were fully continent during day-time, three had mild night-time incontinence requiring pad use (both patients 1 pad per night). During a mean 11.5 months of follow up, zero patients died. One patient with a pathological, stage 4 tumor, had nodal recurrence at six months postoperatively. No distant metastasis were detected.

Conclusion

Endopelvic fascia sparing RARC has very promising early functional results with safe oncological outcomes and low complication rates.

Super-veil nerve-sparing extraperitoneal pure single-port robotic-assisted radical prostatectomy on da Vinci Si robotic system

OBJECTIVES

To investigate the safety profile and short-term outcome of super-veil nerve-sparing extraperitoneal single-port robotic-assisted radical prostatectomy (espRARP) on da Vinci Si platform.

METHODS

From December 2018 to March 2021, 106 consecutive patients with treatment-naive prostate cancer were prospectively included. espRARP was performed on da Vinci Si surgical platform. Operative time, estimated blood loss, Clavien-Dindo complication classification, continence, potency recovery, quality-of-life scores, and postoperative prostate-specific antigen (PSA) were documented.

RESULTS

Patients aged 52-79 years (mean ± SD, 64.8 ± 6.15 yrs), with a median PSA of 9.2 ng/ml (IQR: 6.70, 16.83) and median prostate volume of 31.9 ml (IQR: 30.01, 38.54). 95.28% (101/106) were clinically localized. All patients underwent espRARP successfully with no open conversions. Operative time was 94.2 ± 30.26 min with an estimated blood loss of 68.5 ml (range, 50-120 ml). No Grade III complications or above were documented. Positive surgical margin was 17.9% (19/106). Median pain score at discharge was 0 (IQR: 0, 1.75) without use of opioid narcotics. Postoperative length of stay was 3 days (IQR: 1, 3), in which 28 patients were discharged within 24 h. Instant, 1-, 3-, and 6 month continence recovery was 18.9, 45.3, 79.2, 93.4, and 96.4%, respectively. Of the 43 patients who received nerve-sparing procedures, 13 (30.23%) resumed potency 6 months postoperatively. 12 month biochemical recurrence-free survival was 92.77% (77/83).

CONCLUSIONS

Extraperitoneal single-port robotic-assisted radical prostatectomy is a safe and feasible technique. Combined with super-veil nerve-sparing procedures, it may provide satisfactory outcome in short-term functional recovery.

Correlation between FA and ADC, number and length of the periprostatic neurovascular fibers

PURPOSE

Our aim was to explore the relation between FA and ADC, number and length of the periprostatic neurovascular fibers (PNF) by means of 1.5 T Diffusion Tensor Imaging (DTI) imaging through a multivariate linear regression analysis model.

METHODS

For this retrospective study, 56 patients (mean age 63.5 years), who underwent 1.5-T prostate MRI, including DTI, were enrolled between October 2014 and December 2018. Multivariate regression analysis was performed to evaluate the statistically significant correlation between FA values (dependent variable) and ADC, the number and the length of PNF (independent variables), if p-value <0.05. A value of 0.5 indicated poor agreement; 0.5-0.75, moderate agreement; 0.75-0.9, good agreement; 0.61-0.80, good agreement; and 0.9-1.00, excellent agreement.

RESULTS

The overall fit of the multivariate regression model was excellent, with R² value of 0.9445 (R² adjusted 0.9412; p < 0.0001). Multivariate linear regression analysis showed a statistically significant correlation (p < 0.05) for all the three independent variables. The r partial value was -0.9612 for ADC values (p < 0.0001), suggesting a strong negative correlation, 0.4317 for the number of fiber tracts (p < 0.001), suggesting a moderate positive correlation, and -0.306 for the length of the fiber tracts (p < 0.05), suggesting a weak negative correlation.

CONCLUSIONS

Our multivariate linear regression model has demonstrated a statistically significant correlation between FA values of PNF with other DTI parameters, in particular with ADC.

Combined Open Prostatectomy and Kidney Surgery: Feasibility and 12-Month Outcome

Purpose

There are only a few case reports and case series that investigated combined laparoscopic or robotic surgery for simultaneous prostate and kidney cancer. In this study, we want to close a gap in existing research to assess the feasibility and oncological outcome of combined open prostatectomy and kidney surgery.

Methods

We retrospectively analyzed patients who underwent a combined open prostatectomy and either a partial or complete nephrectomy from 2013 to 2020. Descriptive statistics were used to assess perioperative parameters and the 12-month functional and oncological outcomes after combined surgery.

Results

We identified 10 patients undergoing combined open surgery. Partial nephrectomy was performed in 4, radical nephrectomy in 6 patients. For prostate cancer, histopathological analysis showed a tumor stage ≥ pT2c in all 10 patients. For renal tumors, histopathological analysis showed clear cell renal cell carcinoma in 8 patients and oncocytoma in 2 patients. Operating time was 177 ± 36 minutes. Two perioperative complications (Clavien 2a and 3) were observed. Three months postoperatively, the International Index of Erectile Function (IIEF-5) score was 5.6 ± 5.9, the ICIQ-SF score was 7.3 ± 5.6 and were using 1.9 ± 2.2 pads per day. This improved after 12 months postoperatively, as patients had an IIEF-5 score of 6.33 ± 6.5, an ICIQ-SF score of 4.4 ± 5.7 and were using pads 0.9 ± 1.7 per day.

Conclusion

In this study, we showed that open surgery is a safe and valid approach for combined prostatectomy and renal surgery with acceptable complications and oncological outcomes. The combined open approach could be a good alternative to combined laparoscopic/robotic surgery in this field, especially to treat patients with advanced renal tumors or previous abdominal surgery or radiation.

A Combined Technology to Protect the Anatomic Integrity of Distal Urethral Sphincter Complex in Radical Prostatectomy Improves Early Urinary Continence Recovery Without Sacrifice of Oncological Outcomes

Purpose

Our primary aim was to present a combined technique to protect the anatomic integrity of distal urethral sphincter complex (DUSC) during minimally invasive radical prostatectomy (RP) and discuss its impact on urinary continence (UC) recovery. The second aim was to define the learning curve of the combined technique.

Methods

We conducted a non-randomized retrospective study. There were 314 consecutive patients who received RP by the same urologist surgeon with more than 2,000 prior cases in Shanghai Ruijin Hospital between March 2017 and April 2020. Included in this study were 263 patients with clinical T1–T2 stage. We modified a combined RP (Comb-RP) technique including endopelvic fascia no-incising technique, dorsal venous complex (DVC) no-ligation technique, intrafascial dissection technique, and anterior reconstruction technique so as to preserve the anatomic integrity of DUSC. The patients were assigned to two groups: a Comb-RP group and a conventional RP (Conv-RP) group. Continence rates were assessed every 3 months after removal of the catheter. UC was defined as 0 pad per day. Peri-operative variables of the patient including operation time, estimated blood lost (EBL), positive surgical margin (PSM), and postoperative complications were also collected. Scatter-graphs of learning curves were drawn using locally weighted scatterplot smoothing (LOWESS).

Results

RP was accomplished smoothly in all 263 cases. The pad-free UC rates in Conv-RP group and Comb-RP group were 17.3 vs. 27.8% (P = 0.048) at the removal of the catheter, 35.8 vs. 50.0% (P = 0.027) at 1 month, 60.5 vs. 76.1% (P = 0.012) at 3 months, 87.7 vs. 96.5% (P = 0.022) at 6 months, and 94.7 vs. 97.7% (P = 0.343) at 12 months. Kaplan–Meier analysis showed significantly higher and faster continence recovery in the Comb-RP group (mean 4.9 vs. 2.6 months, Log Rank P = 0.001). There was no significant difference in PSM rate between the Comb-RP and Conv-RP group (31.1 vs. 31.2%, P =0.986). The learning curves of peri-operative variables, oncological and functional outcomes achieved the lowest point or plateau at the 20th–60th cases.

Conclusions

The anatomic integrity and intact pelvic floor interplay of DUSC is important for its function. Our combined technique was a safe and feasible technique for improving early UC in RP with no significantly increased PSM rate and no significant difference in long-term UC.

New Evolution of Robotic Radical Prostatectomy: A Single Center Experience with PERUSIA Technique

Radical prostatectomy (RP) is the standard surgical treatment of organ-confined prostate cancer in patients with a life expectancy of at least 10 years. In a recent prospective study, we described the PERUSIA (Posterior, Extraperitoneal, Robotic, Under Santorini, Intrafascial, Anterograde) technique, which is an extraperitoneal full nerve sparing robotic RP, showing its feasibility and safety. The aim of this retrospective study was to evaluate the peri-operative, oncologic, and functional outcomes of the PERUSIA technique. We retrospectively analyzed the data of 454 robotic-assisted radical prostatectomies (RARP) performed using the PERUSIA technique from January 2012 to October 2019. We evaluated perioperative outcomes (operative time, estimated blood loss, catheterization time, complication rate, length of stay), oncological (positive surgical margins and biochemical recurrence), and functional outcomes in terms of urinary continence and sexual potency. The overall complication rate was 16%, positive surgical margins were 8.1%, and biochemical recurrence occurred in 8.6% at median follow-up of 47 months. Urinary continence was achieved in 69% of cases the day after the removal of the catheter, in 92% at 3 months, and in 97% at 12 months after surgery. The average rate of sexual potency was 72% and 82% respectively 3 and 12 months after surgery. Our findings show that the PERUSIA technique is a safe extraperitoneal approach to perform a full nerve sparing technique providing exciting functional outcomes.

Key pathways in prostate cancer with SPOP mutation identified by bioinformatic analysis

Prostate cancer (PCa) is a leading adult malignant tumor. Recent research has shown that speckle-type BTB/POZ protein (SPOP) mutant is the top frequently mutated gene in PCa, which makes it an important biomarker. In this paper, we aimed at identifying critical genes and pathways related to SPOP mutation in PCa. Recent The Cancer Genome Atlas data showed that 12% of patients with PCa were SPOP mutant. There were 1,570 differentially expressed genes, and online enrichment analysis showed that these genes were mainly enriched in metabolism, pathways in cancer and reactive oxygen species. INS, GNG13, IL6, HTR5A, SAA1, PPY, CXCR5, CXCL13, CD19 and CCL20 were identified as hub genes. The lower SPOP expression level was associated with poor prognosis. In all, our findings showed that various pathways and genes could play critical roles in SPOP mutation in PCa, providing potential options for individualized treatment.

Dorsal Vein Complex Preserving Technique During Robot-Assisted Radical Prostatectomy

Background: Recently, two techniques of robot-assisted radical prostatectomy (RARP), which preserve dorsal vein complex (DVC), endopelvic fascia, and full neurovascular bundle (NVB), through anterior approach were reported. The techniques in a relatively large workspace seem less technically demanding than Retzius-sparing RARP. In this case report, we present a further modified technique of transperitoneal-anterior-antegrade approach with a division of the endopelvic fascia to reduce the technical demands. Case Presentation: In a routine evaluation, a 65-year-old man was shown to have a prostate-specific antigen level of 5.07 ng/mL. Prostatic biopsy revealed a Gleason score of 6 (3 + 3) adenocarcinoma in 2 of the 12 specimens, and the clinical stage was diagnosed as cT2aN0M0. RARP was performed including transperitoneal full NVB sparing, antegrade preservation of DVC, and division of endopelvic fascia to increase the prostate mobility and reduce technical demands. The patient completely gained continence on the day after removal of the catheter, and potency was recovered 30 days after surgery. Conclusion: Our DVC preservation technique in the transperitoneal-anterior-antegrade approach with a division of the endopelvic fascia during RARP may be safe, reduce technical demands, and facilitate early recovery of continence and sexual function after surgery.

Combined Robotic Surgery for Double Renal Masses and Prostate Cancer: Myth or Reality?

With the widespread use of imaging modalities performed for the staging of prostate cancer, the incidental detection of synchronous tumors is increasing in frequency. Robotic surgery represents a technical evolution in the treatment of solid tumors of the urinary tract, and it can be a valid option in the case of multi-organ involvement. We reported a case of synchronous prostate cancer and bifocal renal carcinoma in a 66-year-old male. We performed the first case of a combined upper- and lower-tract robotic surgery for a double-left-partial nephrectomy associated with radical prostatectomy by the transperitoneal approach. A comprehensive literature review in this field has also been carried out. Total operative time was 265 min. Renal hypotension time was 25 min. Blood loss was 250 mL. The patient had an uneventful postoperative course. No recurrence occurred after 12 months. In the literature, 10 cases of robotic, radical, or partial nephrectomy and simultaneous radical prostatectomy have been described. Robotic surgery provides less invasiveness than open surgery with comparable oncological efficacy, overcoming the limitations of the traditional laparoscopy. During robotic combined surgery for synchronous tumors, the planning of the trocars' positioning is crucial to obtain good surgical results, reducing the abdominal trauma, the convalescence, and the length of hospitalization with a consequent cost reduction. Rare complications can be related to prolonged pneumoperitoneum. Simultaneous robotic prostatectomy and partial nephrectomy appears to be a safe and feasible surgical option in patients with synchronous prostate cancer and renal cell carcinoma.

Endorectal power Doppler/grayscale ultrasound-guided biopsies vs. multiparametric MRI/ultrasound fusion-guided biopsies in males with high risk of prostate cancer: A prospective cohort study

Multiparametric MRI fusion with transrectal ultrasound (mpMRI/TRUS)-guided biopsy has the sensitivity of mpMRI with the practicality of TRUS, but males with no cancerous lesion(s) detected on mpMRI have a considerable remaining risk of cancer. Endorectal power Doppler ultrasound improves the sensitivity of grayscale ultrasound-guided biopsies. The objective of the present study was to evaluate the beneficial effect of endorectal power Doppler/grayscale ultrasound-guided biopsy over that of mpMRI/TRUS-guided biopsy for decision-making regarding prostatectomy in males with a high risk of prostate cancer. Data regarding endorectal power Doppler/grayscale ultrasound-guided biopsies and mpMRI/TRUS-guided biopsies of 1,094 males with elevated specific prostate antigen, were included. Radical prostatectomy was performed in males aged <70 years with Gleason scores ≥3+4 in any one of the biopsy reports. The histopathological data of the surgical specimen of 776 males were included in the analysis. Compared to the histopathology of the surgical specimen, endorectal power Doppler/grayscale ultrasound-guided biopsies had a lower sensitivity (0.930 vs. 1.000; P<0.0001) but mpMRI/TRUS-guided biopsies had the same sensitivity (0.990 vs. 1.000; P=0.02). The accuracy of mpMRI/TRUS-guided biopsies was higher than that of endorectal power Doppler/grayscale ultrasound-guided biopsies (0.944 vs. 0.783). On mpMRI, lesions of 105 subjects (10%) with a Likert scale score of <3 were identified. Among them, 14 subjects (2%) had Gleason scores of ≥3+4 as determined by endorectal power Doppler/grayscale ultrasound-guided biopsies. In addition, 20 (2%) false-positive lesions compared to the histopathological analysis of the surgical specimen were identified from mpMRI/TRUS-guided biopsies. In conclusion, mpMRI/TRUS-guided biopsy was indicated to have a moderate performance and endorectal power Doppler/grayscale ultrasound-guided biopsy had a scant performance for decision-making regarding prostatectomy.

Evaluation of Surgical Site Infection in Mini-invasive Urological Surgery

Surgical Site Infection (SSI) is the most frequent source of infection in surgical patients and the second most frequent cause of hospital-acquired infection. The primary aim of this prospective study was to compare SSI occurrences between minimally invasive surgery (MIS) and open urological surgery. Secondly, perioperative outcomes were evaluated in two different approaches. A consecutive group of 60 patients undergoing urological surgery were prospectively enrolled in a single high-volume center between May and October 2018. We included procedures that were performed by minimally invasive or traditional techniques. We evaluated and compared the incidence of SSI and perioperative outcomes in terms of intraoperative bleeding, post-operative complications, postoperative pain, patient satisfaction with the analgesic treatment, time to flatus, time of oral intake and mobilization, and length of hospital stay. The two groups were homogeneous with regard to demographic data. Superficial incisional SSIs were diagnosed in 10% of cases (3/30) in the second group and 0% in the first (p<0.05); space/organ SSIs developed in 4 patients, which were diagnosed by ultrasound scan and confirmed by abdominal CT: 1 patient (3.3%) in group 1 showed an infected lymphocele, whereas 1 case of infected lymphocele and 2 cases of pelvic abscess were detected in group 2 (10%, p<0.05). All the perioperative outcomes as well as were overall complication rate favored MIS (p<0.05). The use of minimally invasive techniques in urological surgery reduced the risk of SSI by comparison with a traditional approach. In addition, MIS was associated with better perioperative outcomes and a lower overall complication rate.

The accumulation of metabolic syndrome components is associated with higher risk of positive surgical margin among patients with localized prostate cancer after radical prostatectomy

Objective

To evaluate the association between metabolic syndrome (MetS) and the accumulation of its components with prostate cancer (PCa).

Patients and methods

Patients undergoing radical prostatectomy were retrospectively included. Patients were grouped by low risk and intermediate-high risk according to International Society of Urological Pathology grade. Multivariable logistic regression and Cox hazard regression model were utilized to assess the association of MetS with overall survival, biochemical recurrence, upgrading, upstaging, and positive surgical margin (PSM) after prostatectomy. Besides, trend test was also performed to evaluate the impact of the accumulation of MetS components on postoperative pathological feature.

Results

A total of 1,083 patients were eventually enrolled. With a median follow-up of 40.45 months, 197 patients were diagnosed with MetS. No significant association between MetS and survival outcomes and pathological features was found. However, we did notice that the accumulation of the MetS components could lead to an elevated gradient of the PSM risk in the entire cohort (one component: OR=1.46; two components: OR=1.89; ≥3 components: OR=2.07; P for trend=0.0194) and intermediate-high risk group (one component: OR=1.4; two components: OR=1.85; ≥3 components: OR=2.05; P for trend=0.0127).

Conclusion

The accumulation of MetS components could lead to increasing risk of PSM on the entire PCa cohort and patients with intermediate-high risk PCa after prostatectomy, but not for the low-risk patients.

Uroflow stop test with electromyography: a novel index of urinary continence recovery after RARP

PURPOSE

Urinary incontinence (UI) is one of the most bothersome surgical side effects after robot-assisted radical prostatectomy (RARP). Alteration of both smooth and striate urethral sphincter occurs after RARP. Since the contraction of perineal muscles is involved in the complex mechanism of urinary continence, the uroflow stop test (UST) seems to predict early continence recovery after RARP. The UST was added of perineal surface electromyography (EMG) evaluation to evaluate the latency time (LT) between muscular contraction and the complete stop of urine flow. Our aim was to present UST-EMG as a new tool in the investigation of UI, implying pelvic floor integrity, and to evaluate whether an early return (≤ 3 months) to preoperative LT could be associated with early recovery of UC (≤ 3 months).

METHODS

After prospectively enrolling 137 patients who underwent RARP with a minimum follow-up of 6 months, we identified two groups: Group 1 (93 patients) with early (≤ 3 months) pre-surgical LT recovery and Group 2 (44 patients) with late > 3 months or not able to reach pre-surgical LT recovery.

RESULTS

Between the two groups, there were significant differences in terms of different surgical technique (nerve-sparing versus non-nerve-sparing) and pads use at 3 and 6 months after RARP (p < 0.05). No differences were recorded neither in postoperative maximum flow-rate, nor in postoperative symptoms score.

CONCLUSIONS

UST with EMG can be considered as a noninvasive, reproducible and easily performable tool. LT is applicable in the clinical evaluation to predict urinary continence recovery after RARP.