Intermediate-term Oncologic Outcomes Research Articles

Oncological Outcomes Following Robotic Postchemotherapy Retroperitoneal Lymph Node Dissection for Testicular Cancer: A Worldwide Multicenter Study

Oncological Outcomes Following Robotic Postchemotherapy Retroperitoneal Lymph Node Dissection for Testicular Cancer: A Worldwide Multicenter Study

Five-year Oncologic Outcomes Following Primary Partial Gland Cryo-ablation Prospective Cohort Study of Men With Intermediate-risk Prostate Cancer

To assess 5-year oncologic outcomes following primary partial gland cryo-ablation (PPGCA) in intermediate-risk prostate cancer. Of 476 men undergoing PPGCA enrolled in our prospective oncologic and functional outcomes study, 313 had magnetic resonance imaging (MRI) concordant intermediate-risk prostate cancer with no out-of-field Gleason grade group ≥2, gross extracapsular extension, or extreme apical disease on pre-treatment multi-parametric MRI. Prostatic-specific antigen was monitored every 6months, and multi-parametric MRI at 6 to 12, 24, 42, and 60months. Protocol biopsies at 6-12 months and 24months were discontinued after interim analysis showing low rates of clinically significant prostate cancer (csPCa) defined as any Gleason grade group ≥2 disease. Freedom-from-failure was defined as no prostate cancer-specific mortality, metastatic disease, or whole-gland salvage treatment. csPCa was detected in 33 (10.5%) subjects. Ninety-one had ≥4.5years of follow-up data with a mean of 8.9, 3.4, and 2.0 surveillance prostatic-specific antigen tests, MRIs, and prostate biopsies; none were lost to follow-up. At 5years, rates of freedom-from-recurrence of in-field, out-of-field, and overall csPCa were 86% (95% confidence interval [CI]: 78-96), 85% (95% CI: 63-94), and 70% (95% CI: 57-84). The proportion with freedom-from-failure at 5years was 89% (95% CI: 83-95). None died from prostate cancer, 1 (1%) developed metastasis, 15 (16.5%) underwent whole-gland salvage treatment, and 15 (16.5%) underwent salvage focal therapy. Only 3 of 91 (3.3%) eligible men were non-compliant with 5-year surveillance protocol. Very encouraging intermediate-term oncological outcomes following PPGCA were observed with very high compliance to a rigorous prospective protocol for identifying recurrent csPCa.

Minimally invasive thymectomy for patients with thymoma: surgical, oncological and neurological outcomes.

Traditionally, sternotomy has been the gold standard approach for the treatment of thymomas. However, interest in minimally invasive techniques such as video-assisted and robot-assisted thymectomy is gaining momentum. Concerns have been raised over the possibility of en-bloc resection using minimal access techniques due to limited working space and increased tumour manipulation leading to tumour breach and recurrence. An observational cohort study was conducted at a tertiary referral centre from 1 April 2012 to 31 December 2020 and followed up until 31 March 2023. Consecutive patients of thymoma were evaluated for demography, symptoms and imaging preoperatively and included for the study. Post minimally invasive thymectomy, surgical, neurological and oncological outcomes were evaluated through out-patient and telephonic follow-up. Fifty-two patients underwent minimally invasive thymectomy. Video-assisted thoracoscopic surgery for thymectomy was used in 49 patients (94.2%) with 3 (5.8%) patients undergoing robot-assisted thoracoscopic surgery. Median tumour size was 4cm (interquartile range (IQR)3-5) with a median operative duration of 150min (IQR 120-180), blood loss of 135ml (IQR 42.5-250), post-operative stay of 3days (IQR 2-4) and no 30-day surgery related morbidity and mortality. Annual contrast-enhanced computed tomography imaging, available in 46 (88.5%) patients, showed no recurrence at a median follow-up of 43 (IQR, 21-75) months. No symptoms suggesting recurrence was noted at a median clinical follow-up of 57 (IQR 44-95.5) months and 88.5% patients were expected to survive a period of 10years. Minimally invasive thymectomy is technically feasible with minimal morbidity and acceptable intermediate-term oncological outcomes in patients suffering with thymoma. Institute ethical committee approval: Ref no. IECPG-551/14.11.2018.Clinical Trial Registry of India: Ref no. CTRI/2019/04/018784.

Intermediate-Term Oncologic Outcome Assessment for Robot-Assisted Radical Prostatectomy: Comparing Retzius-Sparing with Standard Approach in a Randomized Control Cohort.

Introduction: Retzius-sparing prostatectomy was promoted with the early continence result. The long-term oncologic outcome is still unknown. In this study, we aimed to compare the intermediate-term oncologic outcomes of these two approaches in patients' cohort who were treated as part of a randomized controlled trial. Methods: A total of 120 patients were previously randomized equally to receive Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RS-RARP) vs standard robot-assisted laparoscopic radical prostatectomy (S-RARP) between January 2015 and April 2016. Baseline, surgical, and pathologic characteristics as well as oncologic outcomes were assessed. The analysis was done based on the treatment received. Result: Sixty-three patients underwent S-RARP, whereas 57 patients underwent RS-RARP. There was no statistically significant difference in the baseline nor surgical characteristics. The median follow-up was 71.24 (interquartile range: 59.75-75.75) months. There were more pathologic T3 diseases in RS-RARP. There was no significant difference in the positive margin status nor in the biochemical recurrence (BCR) rate among both groups. After S-RARP and RS-RARP, 6 and 10 patients had BCR, and the 5 years BCR-free survival was 91% and 85%, respectively (p = 0.21). Conclusion: In this cohort, there was no difference in BCR in the patients who received either technique. Further multi-institutional studies with a larger sample size and longer follow-up are required.

An Updated Systematic Review and Meta-Analysis on the Technical, Oncologic, and Safety Outcomes of Microwave Ablation in Patients with Renal Cell Carcinoma.

Introduction: Percutaneous microwave ablation (MWA) has emerged as a new energy modality for percutaneous renal tumor ablation with potential advantages over radiofrequency and cryoablation. The goal of our study was to determine MWA outcomes for suspicious renal masses, with a subset analysis for biopsy-proven renal cell carcinoma (RCC) and larger (T1b) tumors. Methods: Studies reporting outcomes of MWA for RCC were identified. Random-effects models with inverse-variance weighting were used to pool outcomes, including technical success rate (TSR), technical efficacy rate (TER), local recurrence rate (LRR), cancer-specific survival rate (CSSR), overall survival rate (OSR), and complications. Results: Among 914 studies captured, 27 studies with 1584 patients (1683 malignant renal tumors) were included. The pooled TSR and TER were 99.6% (95% confidence interval [CI], 98.0%-100%) and 96.2% (95% CI, 93.8%-98.2%). The pooled LRR was 3.2% (95% CI, 1.9%-4.7%). At 1, 3, and 5 years, the pooled CSSRs were 100% (95% CI, 99.4%-100%), 100% (95% CI, 98.4%-100%), and 97.7% (95% CI, 94.5%-99.7%), while pooled OSRs were 99.0% (95% CI, 97.5%-99.9%), 96.0% (95% CI, 93.1%-98.3%), and 88.1% (95% CI, 80.3%-94.2%). The pooled minor and major complication rates were 10.3% (95% CI, 7.1%-13.9%) and 1.0% (95% CI, 0.3%-2.1%). In 204 patients with 208 T1b tumors, the pooled TSR and TER were 100% (95% CI, 96.6%-100%) and 85.2% (95% CI, 71.0%-95.8%). The pooled LRR was 4.2% (95% CI, 0.9%-8.9%). At 1, 3, and 5 years, the pooled CSSRs were 98.2% (95% CI, 88.7%-100%), 97.2% (95% CI, 78.5%-100%), and 98.1% (95% CI, 72.3%-100%). At 1 and 3 years, the pooled OSRs were 94.3% (95% CI, 85.7%-99.6%) and 89.3% (95% CI, 68.7%-100%). The pooled minor and major complication rates were 14.8% (95% CI, 7.4%-23.8%) and 2.6% (95% CI, 0%-7.8%). Conclusions: MWA demonstrated favorable short- to intermediate-term oncologic outcomes with low complication rates, including in the T1b subset, with moderate quality of data and heterogeneity of assessed outcomes. This supports MWA as a safe and effective treatment for RCC and a potential viable option for larger tumors.

Advancing Treatment Frontiers: Radiofrequency Ablation for Small Renal Mass-Intermediate-Term Results.

Our study aims to discern the immediate and intermediate-term oncological outcomes of the patients with small renal mass and who were surgically unfit or were having a bilateral tumor and underwent radiofrequency ablation (RFA) of the mass. We retrospectively and prospectively analyzed the status of the patients who were diagnosed to have small renal masses and were biopsy-proven renal cell carcinoma (RCC) cases, who underwent RFA at our institute from the year 2013 to 2022. Patients were followed-up for 3 years. Data regarding complications were analyzed for all patients who underwent renal RFA along with the 3-year recurrence-free survival (RFS) rate. A total of 28 patients were eligible for the study based on our inclusion and exclusion criteria. Their renal function was recorded. They underwent RFA and were followed-up for a period of 3 years for RFS. Four patients out of the total had immediate complications, out of which two developed a hematoma. Three-year-follow-ups showed six recurrences, overall having 78.6% RFS. Post-procedural renal function was stable as documented by Estimated glomerular filtration rate. Oncological results of RFA in patients with small renal masses who are surgically unfit are associated with a low risk of immediate and intermediate-term deterioration of renal function.

Intermediate-term oncological and functional outcomes in prostate cancer patients treated with perineal robot-assisted radical prostatectomy: A single center analysis

In the last 10 years, robotic platforms allowed to resume of some alternative surgical approaches, including perineal robot-assisted radical prostatectomy (p-RARP). Herein, we present in detail the oncological and functional outcomes of patients who underwent p-RARP with a median follow-up of 30 months. Patients presenting low- or intermediate-risk prostate cancer and prostate volume up to 60mL who underwent p-RARP between November 2018 and November 2022 were selected. Baseline, intraoperative, pathological, and postoperative data were collected and then analyzed. Thirty-seven p-RARP cases were included. Such patients presented mean age of 62 years and a mean Charlson comorbidity index of 4. Body mass index of ≥25kg/m2 was reported by 24 (64.9%) patients, as well as 7 (18.9%) patients reported a past surgical history. Mean prostate volume and median prostate-specific antigen were 41mL and 6.2ng/mL, respectively. The median operative time was 242min. The positive surgical margin rate was 45.9%. In terms of postoperative complications, 10 patients reported complications with any grade; however, a single case (2.7%) of major (Clavien-Dindo grade ≥3) complication was observed. No patient with biochemical recurrence or distant metastasis was reported at 2 years of follow-up. Recovery of continence rates were 67.6%, 75.7%, and 92.9%, at 6 months, 12 months, and 24 months after surgery, respectively. p-RARP is a challenging but safe minimally invasive approach for selected patients with prostate cancer suitable for radical prostatectomy, showing outstanding functional recovery. Despite positive surgical margin rates being relatively high, no cases of biochemical recurrence or distant metastasis were reported after a median follow-up of 30 months.

Intermediate-term oncological and functional outcomes of salvage cryotherapy for the management of prostate cancer recurrence after primary brachytherapy versus primary cryotherapy: A propensityscore-matched analysis.

Salvage cryotherapy (SCT) is widely used to treat prostate cancer (PCa) recurrence after radiotherapy (RT). We studied the intermediate oncological and functional outcomes of patients who underwent SCT following cryotherapy (CRYO-SCT) recurrence and compare it to recurrence after brachytherapy (BT-SCT). An IRB-approved retrospective cohort study utilizing patient data from the Cryo On-Line DataRegistry and the Duke PCa database between 1992 and 2016. Biochemical recurrence (BCR) using Phoenix criteria was the primary endpoint assessed at 2- and 5-years post-SCT. Secondary endpoints assessed functional outcomes including urinary continence, erectile function, and recto-urethral fistula. Association between treatment and biochemical progression-free survival was assessed using inverse probability weighted (IPTW) Cox proportional hazards regression. The differences in the secondary functional outcomes were assessed by Pearson's χ2 test or Fisher's exact test, corrected for IPTW. A total of 194 patients met inclusion criteria. The BCR rate for BT-SCT and CRYO-SCT was 23 (20.4%) and 17 (21%) at 2 years and 30 (26.5%) and 22 (27.2%) at 5 years according to Phoenix criteria. There was no statistical difference in 2 years(hazard ratio [HR] 0.9; 95% confidence interval [CI], 0.5-1.7, p = 0.7) or 5-year BCR (HR: 0.86; 95% CI, 0.5-1.5, p = 0.6) between the groups. The functional outcomes like urinary continence (p = 0.4), erectile function (p = 0.1), and recto-urethral fistula (p = 0.3) were not statistically different. CRYO-SCT appears to be well tolerated, with comparable oncological and functional outcomes to patients failing primary BT. The findings also demonstrated that SCT can render a significant number of patients biochemically free of disease after initial CRYO with minimal morbidity. SCT is a viable treatment option to salvage local PCa recurrence following either BT or cryoablation failure.

PD27-10 AN INTERMEDIATE-TERM ONCOLOGICAL ASSESSMENT COMPARING THE RETZIUS-SPARING ROBOT ASSISTED RADICAL PROSTATECTOMY TO THE STANDARD APPROACH IN A RANDOMIZED CONTROL COHORT

You have accessJournal of UrologyCME1 Apr 2023PD27-10 AN INTERMEDIATE-TERM ONCOLOGICAL ASSESSMENT COMPARING THE RETZIUS-SPARING ROBOT ASSISTED RADICAL PROSTATECTOMY TO THE STANDARD APPROACH IN A RANDOMIZED CONTROL COHORT Mohit Butaney, Ghassan Barayan, Deepansh Dalela, Sohrab Arora, Alison Levy, Firas Abdollah, James Peabody, Craig Rogers, Mani Menon, and Wooju Jeong Mohit ButaneyMohit Butaney More articles by this author , Ghassan BarayanGhassan Barayan More articles by this author , Deepansh DalelaDeepansh Dalela More articles by this author , Sohrab AroraSohrab Arora More articles by this author , Alison LevyAlison Levy More articles by this author , Firas AbdollahFiras Abdollah More articles by this author , James PeabodyJames Peabody More articles by this author , Craig RogersCraig Rogers More articles by this author , Mani MenonMani Menon More articles by this author , and Wooju JeongWooju Jeong More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003305.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retzius sparing prostatectomy is promoted with the early continence result, but criticized for higher positive surgical margin. The long-term oncological outcome is still unknown. In this study, we aimed to compare the intermediate-term oncologic outcomes of these two approaches in a patient cohort treated as part of a randomized controlled trial. METHODS: A total of 120 patients were previously randomized equally to receive retzius sparing (RS-RARP) versus standard robotic assisted laparoscopic radical prostatectomy (S-RARP) between January 2015 to April 2016. Baseline, surgical, and pathological characteristics as well as oncologic outcomes were assessed. The analysis was done based on the treatment received. RESULTS: Sixty-three patients underwent S-RARP while 57 patients underwent RS-RARP. There was no statistically significant difference in the baseline nor surgical characteristics. The median follow up was 71.24 (IQR 59.75 - 75.75). There were more pathological T3 diseases in RS-RARP. There was no significant difference in the positive margin status nor the biochemical recurrence rate among both groups. After S-RARP and RS-RARP, 6 and 10 patients had biochemical recurrence and the 5 years biochemical recurrence free survival were 91% and 85%, respectively. (p=0.21). CONCLUSIONS: In this cohort, there was no difference in biochemical recurrence in the patients who received either technique. Further multi-institutional studies with a larger sample size and longer follow-up are required. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e745 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohit Butaney More articles by this author Ghassan Barayan More articles by this author Deepansh Dalela More articles by this author Sohrab Arora More articles by this author Alison Levy More articles by this author Firas Abdollah More articles by this author James Peabody More articles by this author Craig Rogers More articles by this author Mani Menon More articles by this author Wooju Jeong More articles by this author Expand All Advertisement PDF downloadLoading ...

Intermediate-term oncological outcomes after a negative endorectal coil multiparametric MRI of the prostate in patients without biopsy proven prostate cancer

Investigate the intermediate-term oncological outcome after negative multiparametric MRI (mpMRI) of the prostate in patients without biopsy proven prostate cancer (PCa). The retrospective study included 121 patients with negative mpMRI (Prostate Imaging Reporting and Data System version 2.1 category<3) performed at our institution between 2012 and 2017 without known biopsy proven PCa. Clinical and pathological data were collated including post-MRI prostatic tissue diagnoses with highest Grade Group and most recent prostate specific antigen (PSA) levels up to any definitive prostate cancer treatment. Mean PSA velocities between patients with and without a subsequent diagnosis of Grade Group 2 or higher (GG2+) PCa were compared, and an optimal threshold value was calculated. Outcome data available included PSA values in 117 patients and prostate tissue sampling in 52 patients. Over a median follow up interval of 49.8months, only 11 of 121 patients (9.1%) were diagnosed with GG2+ PCa, 10 patients (8.3%) with GG1 PCa, and 31 patients (25.6%) had negative prostate tissue samples. Mean PSA velocity was significantly higher in the patients diagnosed with GG2+ PCa (3.87ng/mL/year) compared to those not diagnosed with GG2+ PCa (-0.71ng/mL/year, p<0.001). A threshold PSA velocity of 0.27ng/mL/year had a 100% sensitivity and 69.8% specificity for GG2+ PCa (AUC: 0.898). <10% of patients with negative mpMRI without prior biopsy proven PCa were diagnosed with GG2+ PCa over median follow up of over four years and were associated with PSA velocity of ≥0.27ng/mL/year. PSA monitoring may be a reasonable management strategy in patients with a negative mpMRI without biopsy proven PCa.

Irreversible Electroporation for the Treatment of Small Renal Masses: 5-Year Outcomes.

Introduction: Irreversible electroporation (IRE) is a nonthermal ablative technology that applies high-voltage short-pulse electrical current to create cellular membrane nanopores and ultimately results in apoptosis. This is thought to overcome thermal limitations of other ablative technologies. We report 5-year oncologic outcomes of percutaneous IRE for small renal masses. Patients and Methods: A single-institution retrospective review of cT1a renal masses treated with IRE from April 2013 to December 2019 was performed. Those with <1 month follow-up were excluded. IRE was performed with the NanoKnife© System (Angiodynamics, Latham, NY). Renal mass biopsy was obtained before or during ablation in most circumstances; biopsy was excluded in some patients because of concern for IRE probe displacement. Postablation guideline-based surveillance imaging was performed. Initial treatment failure was defined as persistent tumor enhancement on first post-treatment imaging. Survival analysis was performed through the Kaplan-Meier method for effectively treated tumors (SPSS; IBM, Armonk, NY). Results: IRE was used to treat 48 tumors in 47 patients. Twenty-two per 48 tumors (45.8%) were biopsy-confirmed renal cell carcinoma (RCC). No complications ≥ Clavien Grade III occurred and 36 patients (76.6%) were discharged the same day. Initial treatment success rate was 91.7% (n = 44/48); three treatment failures were managed with salvage radiofrequency ablation and one with robotic partial nephrectomy. Median follow-up was 50.4 months (interquartile range 29.0-65.5). The 5-year local recurrence-free survival was 81.4% in biopsy-confirmed RCC patients and 81.0% in all patients. Five-year metastasis-free survival was 93.3% and 97.1%, respectively, and 5-year overall survival was 92.3% and 90.6%, respectively. Five-year cancer-specific survival was 100% for both biopsy-confirmed RCC and all patient groups. Conclusions: IRE has low morbidity, but suboptimal intermediate-term oncologic outcomes compared with conventional thermal ablation techniques for small low-complexity tumors. Use of IRE should be restricted to select cases.

IJU this issue

This issue deals with a wide range of clinical topics of urology, and contains one Guideline, 15 Original Articles, and three Urological Notes. The Clinical Practice Guidelines for Bladder Cancer were first published in 2009, and the first revision (2nd edition) was in 2015. Here, Matsumoto et al. (Ube, Japan) demonstrated a summary of the second revision in 2019 (3rd edition). There has been a major paradigm shift in the daily clinical practice of urology during the 4 years from the second edition to the present revision. Of note is the emergence of immune checkpoint inhibitors and the rapid dissemination of robot-assisted surgery. In this summary, clinical topics that contribute to the decision to change treatment regimens in response to such a large paradigm shift are selected and included as clinical questions. This issue also includes two interesting articles regarding bladder cancer. Weiner et al. (Chicago, USA) assessed the use of surgical resection of metastatic disease in a large national sample and its association with overall survival. They demonstrated that the use of metastasectomy for bladder cancer is low, although metastasectomy is associated with longer overall survival and in multiple subgroups. Of course, these results should be validated in future studies. As evidence supporting robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) remained limited so far, Tan et al. (Singapore) compared the perioperative and oncological outcomes between iRARC versus open cystectomy (ORC) for bladder cancer in a contemporary Enhanced Recovery After Surgery cohort. They demonstrated that iRARC has perioperative benefits of lower estimated blood loss, with a trend toward faster bowel recovery and a shorter duration of opioid analgesia when compared with ORC. In addition, iRARC also achieved similar intermediate-term oncological and survival outcomes to ORC. Despite being the most common malignancy in men and the second leading cause of cancer-related deaths among men in the USA, the benefits of screening for prostate cancer remains more controversial than any other types of cancer screening. Leong et al. (Philadelphia, USA) examined the predictors of prostate-specific antigen (PSA) discussion with a physician and PSA testing in men aged ≥55 years. They demonstrated that significant inequalities in PSA testing and discussion exist among men in the USA, mainly driven by socioeconomic factors such as marital status, education, income, etc. Therefore, a better understanding of the socioeconomic factors influencing PSA testing/discussions can inform strategies to reduce existing gaps in care. Renal cell carcinoma is highly resistant to chemotherapy and radiation therapy, and surgical resection is the standard of care for early-stage disease. However, patients with advanced and metastatic disease have limited treatment options, and long-term survival for these patients is approximately 10%. Obeng et al. (Atlanta, USA) evaluated clear cell renal cell carcinoma-related gene mutations potentially associated with aggressive disease, sarcomatoid differentiation, or poor prognosis. Although there are pitfalls due to intratumoral heterogeneity and sampling bias, their results demonstrated that mutations in PBRM1 may be associated with metastasis and aggressive disease in clear cell renal cell carcinoma. Urolithiasis is one of the most frequently diagnosed urological diseases, and its prevalence is increasing throughout the world, including Japan. Hori et al. (Tokyo, Japan) developed a novel simple quantitative scoring system termed the T.O.HO. score consisting of three stone characteristics, (T)allness (1–5 points), (O)ccupied lesion (1–3 points), and (HO)unsfield units evaluation (1–3 points), for predicting stone-free status after a flexible ureteroscopy lithotripsy procedure by standardizing the complexity of ureteral stone characteristics. They reported that the T.O.HO. score is a useful tool for predicting stone-free status in patients who have undergone a flexible ureteroscopy lithotripsy procedure. None declared.

Inguinal lymph node dissection in the era of minimally invasive surgical technology.

Inguinal lymph node dissection (ILND) is an essential step in both treatment and staging of several malignancies including penile and vulvar cancers. Various open, video endoscopic, and robotic-assisted techniques have been utilized so far. In this review, we aim to describe available minimally invasive surgical approaches for ILND, and review their outcomes and complications. The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000-2020. There are different minimally invasive platforms available to accomplish dissection of inguinal nodes without jeopardizing oncological results while minimizing postoperative complications. Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy are safe and achieve the same nodal yield, a surrogate metric for oncological adequacy. When compared to open technique, Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy may offer faster postoperative recovery and fewer postoperative complications including wound dehiscence, necrosis, and infection. The relatively high rate and severity of postoperative complications hinders utilization of recommended ILND for oncologic indications. Minimally invasive approaches, using laparoscopic or robotic-assisted platforms, show some promise in reducing the morbidity of this procedure while achieving adequate short and intermediate term oncological outcomes.

Intermediate oncologic outcomes after uniportal video-assisted thoracoscopic thymectomy for early-stage thymoma.

BackgroundRecent years have seen a trend towards utilizing a video-assisted thoracic surgery (VATS) approach for treatment of thymoma. Although increasing in practice, intermediate- and long-term oncologic outcome data is lacking for the VATS approach. There is no oncologic data for the uniportal VATS approach. We sought to evaluate the feasibility and impact on patient survival of uniportal VATS thymectomy for early-stage thymoma.MethodThe clinical outcomes for 17 patients with Masaoka stage I to II thymomas treated between January of 2009 and July of 2014 at a single institution were collected retrospectively. Primary endpoint was overall survival (OS) and secondary endpoint was recurrence-free survival (RFS).ResultsTen women and seven men underwent uniportal VATS thymectomy; eleven had stage I thymoma and six had stage II thymoma. There were no conversions to open surgery. Operative mortality was zero. Mean tumor size was 3.8±1.0 centimeters, with a range of 1.9 to 6.0 centimeters. All patients underwent a R0 resection. Five-year survival was 100%, and the estimated RFS was 100%.ConclusionsOur findings suggest that uniportal VATS thymectomy for early-stage thymoma is feasible, and the intermediate-term oncologic outcomes are comparable to historic standards for open and multi-incision VATS thymectomy. However, additional follow-up is required to evaluate for long-term oncologic outcomes.

Benefits of robotic cystectomy compared with open cystectomy in an Enhanced Recovery After Surgery program: A propensity-matched analysis.

To compare the perioperative and oncological outcomes between robot-assisted radical cystectomy with intracorporeal urinary diversion versus open cystectomy for bladder cancer in a contemporary Enhanced Recovery After Surgery cohort. All consecutive patients who underwent radical cystectomy and managed under an Enhanced Recovery After Surgery protocol, from December 2013 to October 2018, were reviewed. Propensity score adjustment was carried out to reduce biases attributable to covariate imbalances. There were 19 robot-assisted radical cystectomy with intracorporeal urinary diversion and 21 open cystectomy patients. The robot-assisted radical cystectomy with intracorporeal urinary diversion cohort was associated with lower estimated blood loss (397 vs 787mL, P=0.05), with a trend toward shorter duration of ileus and postoperative opioid administration. These benefits were apparent, despite a longer operative time (581 vs 446 mins, P=0.03), a higher proportion of orthotopic bladder reconstruction (26.3 vs 9.5%, P=0.08), a more prevalent use of neoadjuvant chemotherapy and a higher number of salvage cystectomies for the robot-assisted radical cystectomy with intracorporeal urinary diversion group. Comparable perioperative complications and length of hospital stay were observed. The pathological and intermediate oncological outcomes were similar in both groups (locally advanced disease: 52.6 vs 47.6%, P=0.85; lymph node yield: 29 vs 34, P=0.23). The mean recurrence-free survival and overall survival in the robot-assisted radical cystectomy with intracorporeal urinary diversion group was 37.5 and 43.0months, respectively, compared with 21.4 (P=0.09) and 35.5 (P=0.14) months, respectively, in open cystectomy. Robot-assisted radical cystectomy with intracorporeal urinary diversion has perioperative benefits of lower estimated blood loss, with a trend toward faster bowel recovery and a shorter duration of opioid analgesia when compared with open cystectomy. Robot-assisted radical cystectomy with intracorporeal urinary diversion also achieves similar intermediate-term oncological and survival outcomes.

The Effect of Surgical Experience on Perioperative and Oncological Outcomes After Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Evidence from a Referral Centre with Extensive Experience in Robotic Surgery

Evidence on the learning curve for robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is limited. To assess the effect of surgical experience (SE) on perioperative and intermediate-term oncological outcomes in a large contemporary cohort of RARC patients after accounting for the impact of intersurgeon variability. The study cohort included 164 patients treated with RARC and ICUD by two surgeons between 2004 and 2017 at a single European referral centre. For each patient, SE was defined as the total number of RARCs performed by each surgeon before the patient's operation. The relationship between SE and operative time (OT), lymph node yield (LNY), positive surgical margins (PSMs), Clavien-Dindo grade ≥2 30-d postoperative complication (CD≥2), and oncological outcomes (18-mo recurrence rate) was evaluated in multivariable linear and logistic regression models, clustering at a single-surgeon level. After adjusting for case mix, SE was associated with shorter OT (p= 0.003), lower probability of postoperative CD≥2 rates (p= 0.01), and lower 18-mo recurrence rates (p= 0.002). Conversely, SE did not predict lower PSM rates (p= 0.3) and higher LNY (p= 0.4). The relationship between SE and OT was nonlinear, with a plateau observed after 50 cases. Conversely, the relationship between SE and CD≥2 and 18-mo recurrence was linear without reaching a plateau after 88 procedures. SE affects perioperative and oncological outcomes after RARC with ICUD in a linear fashion, and its beneficial effect does not reach a plateau. Conversely, after 50 cases, no further improvement was observed for OT. Robot-assisted radical cystectomy with intracorporeal urinary diversion is a complex surgical procedure with a relatively long learning curve.

Comparison of Decompressing Stoma vs Stent as a Bridge to Surgery for Left-Sided Obstructive Colon Cancer

Bridge to elective surgery using self-expandable metal stent (SEMS) placement is a debated alternative to emergency resection for patients with left-sided obstructive colon cancer because of oncologic concerns. A decompressing stoma (DS) might be a valid alternative, but relevant studies are scarce. To compare DS with SEMS as a bridge to surgery for nonlocally advanced left-sided obstructive colon cancer using propensity score matching. This national, population-based cohort study was performed at 75 of 77 hospitals in the Netherlands. A total of 4216 patients with left-sided obstructive colon cancer treated from January 1, 2009, to December 31, 2016, were identified from the Dutch Colorectal Audit and 3153 patients were studied. Additional procedural and intermediate-term outcome data were retrospectively collected from individual patient files, resulting in a median follow-up of 32 months (interquartile range, 15-57 months). Data were analyzed from April 7 to October 28, 2019. Decompressing stoma vs SEMS as a bridge to surgery. Primary anastomosis rate, postresection presence of a stoma, complications, additional interventions, permanent stoma, locoregional recurrence, disease-free survival, and overall survival. Propensity score matching was performed according to age, sex, body mass index, American Society of Anesthesiologists score, prior abdominal surgery, tumor location, pN stage, cM stage, length of stenosis, and year of resection. A total of 3153 of the eligible 4216 patients were included in the study (mean [SD] age, 69.7 [11.8] years; 1741 [55.2%] male); after exclusions, 443 patients underwent bridge to surgery (240 undergoing DS and 203 undergoing SEMS). Propensity score matching led to 2 groups of 121 patients each. Patients undergoing DS had more primary anastomoses (104 of 121 [86.0%] vs 90 of 120 [75.0%], P = .02), more postresection stomas (81 of 121 [66.9%] vs 34 of 117 [29.1%], P < .001), fewer major complications (7 of 121 [5.8%] vs 18 of 118 [15.3%], P = .02), and more subsequent interventions, including stoma reversal (65 of 113 [57.5%] vs 33 of 117 [28.2%], P < .001). After DS and SEMS, the 3-year locoregional recurrence rates were 11.7% for DS and 18.8% for SEMS (hazard ratio [HR], 0.62; 95% CI, 0.30-1.28; P = .20), the 3-year disease-free survival rates were 64.0% for DS and 56.9% for SEMS (HR, 0.90; 95% CI, 0.61-1.33; P = .60), and the 3-year overall survival rates were 78.0% for DS and 71.8% for SEMS (HR, 0.77; 95% CI, 0.48-1.22; P = .26). The findings suggest that DS as bridge to resection of left-sided obstructive colon cancer is associated with advantages and disadvantages compared with SEMS, with similar intermediate-term oncologic outcomes. The existing equipoise indicates the need for a randomized clinical trial that compares the 2 bridging techniques.

Primary robotic RLPND for nonseminomatous germ cell testicular cancer: a two-center analysis of intermediate oncologic and safety outcomes.

To evaluate the intermediate-term oncologic outcomes and safety profile of the largest case series of primary robotic retroperitoneal lymphadenectomy for low-clinical-stage non-seminomatous germ cell testicular cancer. This was a two-center retrospective analysis of robotic RPLND cases for low-clinical-stage (stage I-IIB) non-seminomatous germ cell testicular cancer in the primary setting. Demographic, perioperative, operative and oncologic variables were collected between March 2008 and May 2019. Descriptive analyses were performed and presented as medians with interquartile ranges for continuous variables and frequency and proportions for categorical variables. A survival analysis of time to recurrence was performed using Cox proportional hazards model. Using logistic regression, risk factors for complications were analyzed. Both univariate and multivariate analyses were performed. A total of 58 patients (CS 1 = 56, CS IIA = 2, CS IIB = 0) were identified. The median follow-up was 47months and the 2-year recurrence-free survival rate was 91%. The five recurrences were all out of the performed dissection template (pelvis = 1 and lung = 4). Only five patients (29%) with occult metastasis underwent adjuvant chemotherapy. The median operative time was 319min [interquartile range (IQR) 276-355min], estimated blood loss was 100ml (IQR 75-200ml), node count was 26 (IQR 20-31), and length of stay 2 d (IQR 1-3days). There were 2 (3.3%) intraoperative complications, 19 (32.7%) 30-day postoperative complications to include 14 (24.1%) Clavien grade I, 4 (6.9%) Clavien grade II, 1 (1.7%) Clavien grade III and 0 Clavien grade IV complications. No statistical significance was found on multivariate or univariate analysis for survival analysis of time to recurrence and risk factors for complications. This study represents the largest case series of primary R-RPLND for the treatment of low-stage non-seminomatous germ cell tumors (NSGCT). With 47months of follow-up and a low rate of adjuvant chemotherapy, intermediate oncologic efficacy appears to be comparable to the gold standard open approach.

Salvage Prostate Cryoablation for the Management of Local Recurrence After Primary Cryotherapy: A Retrospective Analysis of Functional and Intermediate-Term Oncological Outcomes Associated With a Second Therapeutic Freeze

The purpose of the study was to examine the outcomes of salvage prostate cryoablation for managing patients with local recurrence after primary cryotherapy. The records of 108 patients treated with salvage prostate cryoablation for biopsy-proven local recurrence after primary cryotherapy were retrospectively reviewed. Oncological outcome was defined by the rate of biochemical recurrence (BCR) after salvage ablation using Phoenix criteria. Whole-gland (n= 91; 84.3%) or focal (n= 17; 15.7%) salvage cryoablation after failed primary cryosurgery were used. Fifty-eight of 108 patients (53.7%) had received androgen deprivation therapy (n= 35; 32.4%)/radiotherapy (n= 23; 21.3%) before salvage ablation. Two-year and 5-year BCR rates after salvage therapy were 28.2% and 48.3%, respectively. In univariate analysis, a higher Gleason score, D'Amico risk category (P< .0001) as well as prostate-specific antigen density >0.15 ng/mL/cc (P= .02) before second cryotherapy were significantly associated with the risk of BCR. In multivariable analysis, the only significant factor associated with risk of BCR after the second ablation was a higher presalvage D'Amico risk category (P= .008). Persistent urinary incontinence (1-4 pads per day) in 8 (7.4%), temporary urinary retention in 4 (3.7%), and rectourethral fistula in 4 (3.7%) patients were reported 1 year after second cryoablation. During the same period, 13.8% of patients were able to have either spontaneous or medication-augmented erections sufficient for intercourse. This series, to our knowledge, represents the largest cohort of patients who received 2 cryoablation treatments. Local failure after primary cryoablation can be salvaged by second cryosurgery with acceptable intermediate-term disease control. Patients should be counseled regarding the side effect profile associated with second cryoablation.

A comparison of pathologic and intermediate term oncologic outcomes following open and robotic radical cystectomy.

440 Background: Conflicting data regarding the oncologic efficacy of robotic surgery has led to concerns for possible inferiority. Despite recent prospective results from the RAZOR trial demonstrating non-inferior progression free survival, results from another prospective randomized trial from Memorial Sloan Kettering suggests a possible difference in the pattern of recurrences. We examined our experience with both open (ORC) and robotic radical cystectomy (RRC) with the objective of establishing recurrence patterns and pathologic comparisons at a high volume tertiary referral center. Methods: We performed a retrospective cohort study at a high volume academic tertiary referral center for patients who underwent radical cystectomy (RC) for bladder cancer from 2005 to 2017. The surgical choice of RRC or ORC is based on provider preference. A multivariable analysis was carried out to determine factors predictive of recurrence free survival (RFS) and overall survival after RC. Analysis was done with SAS 9.4. Results: 1813 patients were identified, 10% underwent RRC and no difference in recurrence patterns were found compared to ORC. There was no difference in the severity of pathology distribution between the two cohorts. There was no difference in positive surgical margin status, 2.4% in ORC and 1.1% in RRC. Peritoneal carcinomatosis was seen in 1.1% of ORC and 0.5% in RRC. Shorter RFS was associated with younger age (HR 1.04, 95%CI 1.03-1.05, p&lt;0.001), neoadjuvant chemotherapy (HR1.55 95%CI 1.32-1.82, p&lt;0.001), higher pathologic stage (stage T4 HR 4.38, 95%CI 3.17-6.06, p&lt;0.001), positive lymph nodes at RC (HR 1.82 95%CI 1.53-2.17, p&lt;0.001) and positive surgical margins (HR 1.50 95%CI 1.19-1.89, p&lt;0.001). At a median follow up of 60 months neither progression free or overall survival for ORC compared to RRC was significantly different. Conclusions: The data from this study supports continued use of RRC as a safe oncologic procedure with similar outcomes to ORC.